IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductlons 


institut  Canadian  de  micrcreproductions  historiques 


1980 


Technical  Notes  /  Notes  techniques 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Physical 
features  of  this  copy  which  may  alter  any  of  the 
images  in  the  reproduction  are  checked  below. 


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GZl 
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Coloured  covers/ 
Couvertures  de  couleur 


Coloured  maps/ 

Cartes  giographiques  en  couleur 


Pages  discoloured,  stained  or  foxed/ 
Pages  ddcolories.  tachetdes  ou  piqudes 


Tight  binding  (may  cause  shadows  or 
distortion  along  interior  margin)/ 
Reliure  serr6  (peut  causer  de  I'ombre  ou 
de  la  distortion  le  long  de  la  marge 
intdrieure) 


L'institut  a  microfilm^  le  meilleur  exemplaire 
qu'il  lui  a  dt6  possible  de  se  procurer.  Certains 
difauts  susceptibles  de  nuire  d  la  quality  de  la 
reproduction  sont  notis  ci-dessous. 


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Coloured  pages/ 
Pages  de  couleur 


Coloured  plates/ 
Planches  en  couleur 


Show  through/ 
Transparence 


Pages  damaged/ 
Pages  endommagdes 


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filr 


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ap 

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Additional  comments/ 
Commentaires  suppl^mentaires 


Bibliographic  Notes  /  Notes  bibliographiques 


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Only  edition  available/ 
Seule  Mition  disponible 


Bound  with  other  material/ 
Relid  avec  d'autres  documents 


Cover  title  missing/ 

Le  titre  de  couverture  manque 


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n 


Pagination  incorrect/ 
Erreurs  de  pagination 


Pages  missing/ 
Des  pages  manquent 


Maps  missing/ 

Des  cartes  g^ographiques  manquent 


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Plates  missing/ 

Des  planches  manquent 


Additional  comments/ 
Commentaires  supplAmentaires 


The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Les  images  suivantes  ont  6t6  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettet6  de  I'exemplaire  filmd,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 


The  last  recorded  frame  on  each  microfiche  shall 
contain  the  symbol  —^(meaning  CONTINUED"), 
or  the  symbol  V  (meaning  "END"),  whichever 
applies. 


Un  des  symboles  suivants  apparattra  sur  la  der- 
nidre  image  de  cheque  microifiche,  selon  le  cas: 
le  symbole  —^  signifie  "A  SUIVRE",  le  symbole 
V  signifie  "FIN". 


The  original  copy  was  borrowed  from,  and 
filmed  with,  the  kind  consent  of  the  following 
institution: 

University  de  Sherbrooke 


L'exemplaire  film6  fut  reproduit  grdce  d  la 
g6n6rosit6  de  I'dtablissement  prdteur 
suivant  : 

University  de  Sherbrooke 


Maps  or  plates  too  large  to  be  entirely  included 
in  one  exposure  are  filmed  beginning  in  the 
upper  left  hand  corner,  left  to  right  and  top  to 
bottom,  as  many  frames  as  required.  The 
following  diagrams  illustrate  the  method: 


Les  cartes  ou  les  p!anches  trop  grandes  pour  dtre 
reproduites  en  un  seul  clich6  sont  filmdes  d 
partir  de  Tangle  sup6rieure  gauche,  de  gaurhe  d 
droite  et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  n6cessaire.  Le  diagramme  suivant 
illustre  la  m^thode  : 


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2 

3 

1 

2 

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5 

6 

»r( 


LECTURES 


ON 


CAUSES,   PATHOLOGY,    ANI>  TREATMENT 


OF 


JOINT  DISEASES. 


1)EL[VERED  AT  THE  McGILL  UNIVERSITY  MEDICAL  COLLEGE, 

MONTREAL,  CANADA, 


BY 


LOUIS   BAUER,  M.  D.,  M.  R.  C.  S.,  Eng., 

|)rof(!i$ar  of  ^ntitoms  anb  Clinicnl  ^nrttrg ;  fCirtntiatc  of  t)}t  l^tin  foih  jitittt  jntbiral  JlorUtg 

^Umbtr  of  tlft  ^tto  ^ork  ^nt^ologitnl  J^ocirtg ;  of  tl^t  ^nttrici^n  ^rbital  ^saoiiiition ; 

6aTrt»{ron>ring  ^tUoIs  of  i\it  IHonbon  iRtbtcHl  jSotittQ ;  f,AU  |$e:i(t1f  ^tftctx 

of  l\}t  Sitj)  of  J^vooklnn,  ttc,  tit. 


nEPniNTMD  FROM  THE  CANADA  MEDICAL  JOURNAL. 


NEW  YORK: 
WM.  WOOD  &  CO.,  61  WALKEJ.. 


1868. 


V 


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»  %  % 


CONTJiiNTS. 


Introductory  Remarks. 


1>AGK 
V 


LECTURE  I. 

Causation  of  Joint  Diseases. 

The  strumous  theory  untenable. — Cruveilhier's  experiments. — No  pauper- 
ism, but  joint  diseases  prevalent  in  the  United  States. — Frequency  of 
joint  diseases  in  childhood,  among  boys,  in  cities,  and  more  northern 
latitudes. — Their  rarity  among  adults,  in  the  female  sex,  and  in  the 
south. — The  anti-scrofiilous  treatment  utterly  worthless. — Local  and 
mechanical  treatment  effective. — Traumatic  injuries  the  chief  cause  of 
infantile  joint  diseases 2 

LECTURE  n.  "'kV 

Anatomical  Charactkr  of  ooint  Disbasbs. 

Chondritis  of  rare  occurrence,  if  at  all. — Structure  of  Synovial  lining. — Its 
susceptibility  to  morbid  action. — Richet's  experiments. — Periosteum. — 
Physiological  and  pathological  relation  to  infantile  joints. — Epiphyses, 
their  peculiar  maintenance,  and  exposure  to  traumatic  injuries 14 

LECTURE  in. 

Clinical  Charaoter  of  Joint  Diseases. 

General  symptoms. — Pain,  inflammaiory  and  reflexed. — Immobility. — Spasms 
— Contraction. — Malposition. — Fever. — Protracted  course, — Synovitis. 
— EflFiision. — Loss  of  contour.— Fluctuation. — Suppuration. — Perfora- 
tion.— Hydrops  articuli. — Penetrating  wounds. — Periostitis  and  ostitis. 
—White  swelling. — Affections  of  the  knee-joint. — Morbus  coxarlus Tl 

,       ,    LECTURE  IV. 
Proonosis  of  Joint  Diskasrs. 
Axioms  in. — Prognosis  better  now  than  formerly 41 


I  3  %  3  ^ 


▼Hi.  CONTENTS.  ' 

LECTURE  V. 

Trbatmbnt  of  Joint  Disbasis. 

Method  of  examining. — Importance  of  anaesthesia  for  diagnostic  purposes. 
First  stage. — Absolute  r  ,st  of  joints  the  first  axiom. — Means  of  accom- 
plishing it. — Position  f  r.ffected  articulation  the  next. — Treatment  of 
penetrating  wounds. — Second  stage. — Rest  and  position  imperative. 
Paracentesis  of  joints  beneficial  and  harmless. — Treatment  of  hydrops 
articuli. — Tenotomy. — Free  incisions. — Treatment  of  morbus  coxarius. 
"Wire  apparatus. — Stiffened  bandages. — Portative  splints  and  braces  of 
Davis,  Vedder,  Barwell,  Sayre,  Andrews,  and  Bauer. — Their  respective 
therapeutical  value, — Treatment  of  affections  of  the  knee  joint. — Gutter 
splints. — Knee  brace. — Third  stage. — Exsection  and  amputation. — 
Their  respective  indications 42 

LECTURE  VI. 

Treatment  of  the  SBQcsLifi  of  Joint  Diseases. 

Stiffness  and  its  treatment. — Malposition  and  Anchylosio. — Gradual  exten- 
sion.— Tenotomy. — Brisement  Force. — Louveier. — Dieffenbach. — Lan- 
genbeck, — Accidents, — Rhea  Barton's  operation.— Brain ard's  plan.— 
Deformities  of  Hip  and  Knee-joint. — Their  treatment 67 

CASES. 

I.— Hygroma  Bursale  Traumaticum,  of  eight  years  standing :  fibrous 
anchylosis  of  left  knee.joint  with  flexed  and  inverted  malposition 8<> 

II. — Traumatic  diastasis  of  the  lower  epiphysis  of  left  femur. — Remark- 
able deformity  and  malposition  of  the  knee-joint. — Abnormal  lateral 
mobility. — Total  resection.— Recovery 89 

III. — Morbus  Coxarius  in  its  third  stage.— Consecutive  abscess  connect 
ing  with  the  joint. — Complete  prevention  of  malposition 92 

IV. — Malposition  of  the  right  limb  with  more  than  four  inches  shorten- 
ing, the  result  of  now  extinct  hip  disease 95 


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■"«**''*!*      'V^'--. 


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INTKODUCTIOK 


In  the  succeeding  pages  I  have  set  forth  the  results  of  my  researchss 
into  the  causes,  pathology,  and  treatment  of  articular  diseases.  Whether 
they  are  equivalent  to  tLc*  labours  of  upwards  of  twenty  years,  I  cheer- 
fully leave  to  the  verdict  of  the  unbiassed  portion  of  the  profession. 

But  those  will  be  able  to  form  a  correct  estimate  of  my  humble  eflforts 
in  this  line  of  scientific  culture,  who  compare  the  crude  state  of  surgical 
knowledge  on  the  subject  then  existing,  with  the  rapid  strides  it  has 
made  since  the  ground  was  first  broken  and  prepared  for  the  new  seed. 

I  have  certainly  passed  through  an  eventful  period,  full  of  contentions 
against  preconceived  dogmas,  and  defended  with  the  pertinacity  of  theo- 
logical fanaticism ;  but  I  had  also  my  gratifications  when  the  new  doc- 
trines, elicited  by  careful  pathological  and  clinical  investigations,  forced 
themselves  with  irresistible  logic  into  legitimate  acknowledgment,  and 
now  actuate  the  surgical  practice  of  the  most  prominent  standard-bearers 
of  professional  advancement  both  at  home  and  abroad. 

This  acknowledgment  is  quite  sufficient  to  satisfy  literary  ambition, 
and  I  can  afford  to  treat  with  forbearance  the  literary  piracy  that  has 
availed  itself,  without  due  recognition,  of  the  results  of  my  labours. 

The  opportunity  of  placing  my  literary  products  on  this  subject  on 
record  in  a  more  coherent  and  complete  form,  I  owe  to  the  kind  invitation 
of  the  Medical  faculty  of  the  McGill  University  of  Montreal,  and  I 
cannot  allow  the  occasion  to  pass  without  expressing  my  grateful  appre- 


TimTTBTyr- 


INTRODUCTION. 

'•,•„„„£  the  liberal  tospitality  with  which  I  have  been  treated  by 
d*:  W.  aJof  the  leading  practitioners  of  Montreal  .n 

general.  .    •  n 

,  1       4  Mr  VrsvA  of  New  York,  have  materially 

which  I  employ  in  the  treatment  of  joint  diseases. 


','■  ■■  .-VC'" 


THE  PATHOLOGY  AND  TREATMENT 


OF 


JOINT  DISEASES. 


<  (I 
i\ 

■n 


Gentlemen,— In  compliance  with  your  gratifying  invitation  I  pro- 
pose to  discuss  some  important  points  pertaining  to  articular  diseases. 
This  is  possibly  the  only  subject  with  which  I  may  hope  to  engage  so 
distinguished  an  audience. 

The  last  ten  years  have  been  fruitful  of  material  advancement  both  in 
the  pathology  and  in  the  treatment  of  this  class  of  affections,  and  their 
cultivation  is  still  vigorously  and  diligently  pursued.  Notwithstanding 
all  the  achievements  in  that  direction,  the  subject  still  remains  in  a  state 
of  transition,  through  the  tenacity  with  which  one  portion  of  the  profes- 
sion 'heres  to  the  venerable  teachings  of  the  past,  and  the  enthusiasm 
with  which  another  portion  declares  itself  in  behalf  of  modern  ideas. 
The  time  has  certainly  come  when  an  understanding  should  be  effected 
by  means  of  unbiassed  critical  analysis  and  clinical  experience.  With 
this  object  I  enter  upon  the  present  discourse.  If,  through  inability,  I 
should  fail  of  realizing  my  design,  I  may  at  least  hope  to  place  the  sub- 
ject matter  in  such  attractive  relief  as  to  insure  your  permanent  interest 
and  active  participation  in  the  settlement  of  the  pending  questions. 


2 


I. 


CAUSATION  or  JOINT  DISEASE. 


On  this  point,  there  is  a  decided  clashing  of  views.  By  far  the  larger 
number  of  practitioners,  the  leading  members  of  the  profession  among 
them,  are  of  the  opinion  that  most  cases  of  this  class  are  the  result  of  con- 
stitutional disorder,  of  whi^h  the  articular  affection  is  but  the  localized 
symptom.  To  this  theory  the  most  prominent  authors  on  surgery  are 
committed,  and  it  is  promulgated  from  the  professorial  rostrum  and  at  the 
bed-side.  Time  and  usage  have  even  rendered  it  popular  with  the  laity. 
A  few  modern  enquirers,  comparatively  insignificant  in  name  and  posi 
tion,  not  only  take  exception  to  this  theory  of  causation,  but  assert  that 
articular  maladies  are  excited  exclusively  by  local  causes,  and  that  the 
constitution  bears  no  part  in  the  causation.  They  further  maintain 
that  where  the  constitution  suffers,  it  suffers  from  the  ulterior  effects  of 
the  local  disease. 

As  long  as  etiological  views  on  this  subject  so  widely  diverge,  there 
can  be  no  uniformity  of  treatment ;  nor  can  a  compromise  be  effected 
between  views  so    diametrically  opposite.      The  only  way  of  deciding 
between  two,  of  which  only  one  can  be  right,  is  to  analyse  the  grounds 
upon  which  they  are  respectively  placed.     I  hope  the  venture  on  my  part 
in  doing  so  will  not  be  deemed  presumptuous,  for  the  conflict  of  etiology 
exists,  and  its  settlement  is  certainly  desirable.     Too  much  has  been  al- 
ready conceded  by  the  old  school  to  warrant  a  proud  denial ;  and  no  party 
can  feel  aggrieved  when  appeal  is  made  to  the  decision  of"  stubborn  facts." 
Scrofulosis,  rheumatism,  gout,  syphilis,  scarlatina,  pyemia,  and  other 
diseases  have  been  enumerated  as  constitutional  causes  of  joint  affections. 
To  strumous  disease,  however,  has  been  assigned  the  first  rank,  inasmuch 
as  it  has  been  linked  with  the  numerous  and  diversified  cases  that  happen 
during  childhood.     From  my  own  experience  I  have  to  infer  that  not 
less  than  ninety  per  cent  of  all  articular  affections  occur  before  puberty. 
Inasmuch  as  scrofulosis  is  not  limited  to  childhood,  and  is  supposed  to 
extend  beyond  puberty,  a  few  more  per  cent  nmy  be  added  to  the  origi- 
nal proportion,  making  a  percentage  of  about  ninety-five.     Thus  the 
theory  of  constitutional  causation  narrows  itself  t^own  to  the  theory  of 
strumous  causation,  and  with  this  we  shall  have  essentially  to  deal. 

In  entering  upon  our  investigation,  gentlemen,  we  meet  with  the  sin- 
gular fact,  that  notwithstanding  the  general  acceptance  of,  and  acquies- 
cence in,  the  stated  theory,  nobody  seems  to  know  accurately  what  stru- 
mous disease  really  is.  There  are  certainly  no  two  writers  that  fully 
agree  in  its  definition,  nor  does  scrofulosis  rest  upon  any  firm  pathologi- 


3 


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cal  base.    Even  its  cl'.nical  character  is  rendered  so  indefinite  that  im- 
plicit faith  and  a  goodly  stretch  of  imagination  are  required  to  realize  its 
attributes.     This  is  the  status  of  modern  literature  on  the  subject,  and 
in  extending  our  researches  over  a  more  remote  literary  period,  we  are 
not  less  surprised  to  find  that  the  scrofulosis  of  the  present  is  a  materially 
different  malady  from  that  of  the  past.     The  pathological  school  of  the 
humoralists  has  identified  this  disease  with  a  distinct  morbid  principle,  a 
materia  peccans,  contaminating  nutrition  throughout,  and  stamping  all 
other  incidental  lesions  with  its  peculiar  unalterable  character.     The  fol- 
lowers of  that  school  very  consistently  resorted  to  starvation,  vegetarian- 
ism, and  to  mercurial  and  autimonial  preparations,  for  the  purpose  of  free- 
ing the  system  of  that  c?eMs  efc  machina.     With  the  physiological  school 
the  agent  of  strumous  disease  was  mollified  to  a  mere  imperfect  formation 
of  proteine  compounds.     They  very  wisely  adopted  opposite  treatment 
with  a  view  to  regulate  the  chemical  transactions  of  the  body,  and  to 
correct  the  catalytic  combinations  of  the  proteine.     Both  schools  accept- 
ed perverted  hygiene  and  diet  as  the  remote  causes  of  strumous  disease, 
and  consistently  believed  that  it  was  a  disease  of  pauperism.     Again : 
both  schools  insisted  upon  strumous  diathesis  and  an  hereditary  trans- 
mission.    These  last  views  are  fully  compatible  with  the  humoral ist 
principle  of  pathology,  but  indefensible  from  the  stand-point  of  the  phy- 
siological school.     Certain  appearances  of  patients  may  indicate  perverted 
nutrition,  and  a  i  lorbid  principle,  thereby  engendered,  may,  like  syphilis, 
be  transmitted  t(    generations.     But  a  diathesis  for  the  formation  of 
low-graded  proteine  combinations  is  a  senseless  construction,  and  the 
hereditary  transmission  of  such  compounds  is  equally  without  meaning 
and  inconsistent  with  the  chemical  tenacity  and  restitutive  powers  of  in- 
dividual life. 

Science  in  its  advancement  has  already  made  some  substantial  inroada 
upon  the  strumous  domain,  and  narrowed  its  borders  at  some  vulnerable 
points.  Porrigo  capitis  and  sycosis  menti,  formerly  claimed  as  specific 
strumous  forms,  have  now  been  proven  to  be  caused  by  insignificant 
vegetable  parasites.  The  very  prototype  of  scrofulosis,  viz.,  keratitis 
scrofulosa,  has  been  reclaimed  by  modern  ophthalmologiEts  as  an  inde- 
pendent and  exclusive  local  lesion  readily  yielded  to  local  appliances. 
And  new  incursions  are  threatened  from  oUier  sides.  Help  was  evident- 
ly needed  to  uphold  the  loose  cohesion  of  the  scrofulous  architecture  and 
to  save  it  from  pathological  downfall.  It  was  but  too  readily  found  in 
tuberculosis.  By  incorporating  the  latter  with  strumous  disease,  some 
anatomical  tangibility  was  secured.  Gradually  the  new  pathological  ele- 
ment has  prevailed  so  completely,  that  but  the  name  of  the  old  scrofulous 


doctrine  remains.  In  talking  about  strumous  infiltration,  tuburcular  in- 
jiltration  is  meant ;  and  in  fact  in  its  former  and  present  application,  the 
tubercular  element  has  completely  superseded  the  strumous  one.  The 
transition  from  one  to  the  other  has  been  effected  so  clandestinely  as  to 
be  noticed  but  by  very  few.  The  alliance  between  scrofulosis  and  tuber- 
culosis proves,  if  anything,  that  neither  had  ever  acquired  a  self-sustain- 
ing existence.  Both  diseases  are  clinically  and  anatomically  different  in 
character.  One  is  said  to  prevail  among  children,  the  other  amongst 
adults ;  and  only  exceptionally  is  this  rule  reversed.  The  organ  which 
one  chooses  is  but  rarely  sought  by  the  other.  Their  very  presumed 
causes  differ  most  essentially, — one  said  to  be  the  result  of  poverty  and 
sanitary  defects;  the  other  having  no  respect  for  gradations  of  wealth 
and  station.  They  differ  e\3n  in  geographical  distribution.  Notwith- 
standing all  these  differences,  they  arc,  by  tacit  understanding  and  ac- 
quiescence identified  as  the  same  disease.  It  would  be  unjust,  however, 
to  say  that  this  transition  has  been  effected  totally  without  opposition. 
Of  late  the  pathological  character  of  tuberculosis  has  been  subjected  to 
various  and  close  investigations.  Its  identity  with  pus  has  been  asserted 
by  Cruveilhier.  The  results  of  his  experiments  upon  rabbits  demonstrate 
at  least  this  much,  that  pus  is  susceptible  of  undergoing  the  very  same 
metamorphosis  as  tubercle,  from  the  semi-fluid  condition  to  perfect  inno- 
cuous calcification.  Thfe  strongest  advocates  of  genuine  tuberculosis 
have  been  forced  to  admit  that  there  are  often  pus  corpuscles,  where  the 
external  appearance  of  the  object  denotes  tubercular  substance.  Few  au- 
thors have  had  better  opportunities  of  studying  the  pathological  anatomy 
of  bone  and  joint  diseases  than  Guret  of  Berlin,  his  investigations  extend- 
ing even  over  the  veterinary  field.  If  I  correctly  interpret  his  statement, 
he  has  met  with  no  tubercle  in  joints  and  bones  at  all.  What  other  au- 
thors had  pronounced  to  be  tuberculer  infiltrations  and  caverns,  he 
recognised  as  purulent  infiltration  the  result  of  osteo-myelitis,  and  as  bone 
abscess  the  sequence  of  circumscribed  ostitis.  And  Virchow,  one  of  the 
most  esteemed  pathologists  of  our  time,  considers  himself  justified  in 
stating  that  tubercle  is  fully  compatible  with  the  acknowledged  changes 
of  inflammatory  products.  Again,  gentlemen,  i,?  there  any  peculiarity 
about  tuberculosis  that  could  be  established  and  accepted  ? 

You  are  aware  that  the  so  called  tubercular  cell  has  been  asserted,  but 
the  microscope  has  failed  to  prove  its  reality.  If  the  microscope  cannot 
substantiate  any  peculiarity,  how  much  less  can  the  naked  eye  (  For 
there  is  certainly  no  difference  in  appearance  between  tubercular  matter 
and  cheesy  pus,  and  the  suspicion  of  identity  must  necessarily  accrue  from 
3uch  conformity.    At  any  rate  our  knowledge  on  the  subject  is  not  final 


!S 


m 


and  exhaustive ;   and  we  may  justly  look  for  further  disclosures  rather 
detrimental  to,  than  confirmatory  of,  the  genuine  character  of  tuberculosis. 

But,  to  return  to  the  starting  point  of  our  discourse,  I  shall  find  ample 
occasion  to  show,  that  the  stumous  theory  in  its  practical  application  to 
articular  diseases,  is  worthless  and  rather  injurious  than  otherwise,  as  it 
certainly  has  long  diverted  us  from  a  course  of  investigation  that  alone 
could  lead  to  practical  results. 

Consistently  with  the  received  opinions  the  lower  classes  of  society 
must  come  in  for  their  full  share  of  joint  afibctions  simply  because  they 
are  supposed  to  contend  with  poverty  and  hygienic  neglect.     If  this 
assertion  had  any  show  of  correctness,  it  would  imply  that  where  we  find 
joint  diseases,  there  we  ought  to  expect  poverty  and  hygienic  neglect. 
But  clinical   experience  in  a  great  measure  contradicts  the  assertion. 
These  afiections  happen  in  all  classes  of  society.     They  do  not  pass  the 
mansions  of  the  rich,  nor  are  the  agricultural  districts  exempt  from  their 
visitations.     Yet  with  all  it  must  be  allowed  that  there  is,  in  the  abject 
domestic  condition  of  the  industrial  classes  of  Europe,  a  plausible  reason 
for  assuming  that  they  arc  more  subject  to  chronic   derangements  of 
nutrition  than  the  wealthy  portion  of  society.     Nor  can  the  action  of 
such  nutritive  derangements  upon  local  diseases  be  altogether  denied. 
At  any  rate,   our  patliological  associations   tend  to  confirm  this  supposi- 
tion ;  though  it  may  be  clinically  diflScult  to  qualify  the  exact  measure 
of  those  constitutional  colourings  of  local  lesions.     Those  who  have  had 
the  opportunity  of  personally  investigating  the  actual  social  status  of  the 
European  proletariate  and  pauperism  agree   that  it  is  deplorable  in   the 
extreme.     They  occupy  in  cities  the  worst  of  dwellin.5S,  in  the  lowest  of 
([uarters ;  their  rooms  are  overcrowded,  their  articles  of  food  are  of  in- 
ferior quality ;   multitudes  subsist  from  offal ;   their  opportunities   for 
cleanliness  are  limited  and  little  resorted  to ;  their  very  existence  is  a 
contest  for  the  necessaries  of  life.     Many  of  the  working  classes  and 
paupers  domiciliate  in  places  inaccessible  to  air  and  sunlight,   in  damp, 
and  musty  basements  where  but  fungi  thrive.*     The  combined  effects  of 
these  unfavorable  surroundings  upon  mind  and  body  are  so  appalling  to 
the  humanitarian  as  to  be  remembered  with  painful  sympathy.     They 
give  rise  to  the  most  aggravated  forms  of  so  called  strumous  disease  with 
which  the  public  hospitals  and  dispensaries  are  crowded.     It  is  but  na- 
tural to  associate  so  conspicuous  a  morbific  agency  with  a  class  of  diseases 
seemingly  devoid  of  other  causes,  and  reacting  heavily  upon  the  nutritive 
standard  of  the  patient. 

*  According  to  the  latest  statistics,  10  per  cent,  of  the  entire  population  of 
Berlin,  live  in  cellars  and  basements. 


6 


I  i' 


In  contemplating  the  financial  condition  of  the  same  classes  in  the 
United  States,  we  have  no  difl&culty  in  finding  an  entirely  reversed  status. 
Here  the  demand  for  labor  far  exceeds  the  supply,  and  its  compensation 
has  therefore  for  years  past  been  very  remunerative,  so  as  to  furnish 
ample  income  to  every  individual  who  aspires  to  an  honest  living  by 
handiwork.    The  "  Trades  Associations  "  have,  under  these  circumstances 
readily  succeeded  in  controlling  employers  and  in  imposing  upon  them 
their  own    erms  for  labour.     However  premature  the  eight  hour  labour 
movement  may  have  been,  this  much  is  to  be  inferred  from  it,  that  the 
working  classes  are  almost  the  sole  arbiters  of  their  own  affairs,  much  to 
the  oppression  of  the  other  factor  of  industry.     So  great  has  been  the 
demand  for  hands,   as  to  necessitate  the  employment  of  thousands  of 
women  anu  children.     Nothing  servos  as  better  evidence  of  the  financial 
thrift  of  labour  than  the  acknowledged  prosperous  condition  of  the  Sav- 
ings Bank.     Hence  the  domestic  state  of  the  working  classes  is  infinitely 
superior  to  and  beyond  all  comparison  with  that  of  their  trans- Atlantic 
order.     In  fact  the  humblest  labourer  here  finds  himself  in  the  possession 
of  enjoyments  which  would  be  estimated  as  luxuries  in  Europe.     How 
ever  imperfect  the  tenement  houses  may  be  when  compared  with  the 
dwellings  of  the  wealthier  classes,  still  they  are  comparatively  spacious, 
well-lighted  and  accessible  to  current  ventilation.     The  food  of  the  work- 
ing classes  is  bounteous  and  wholesome,  and  there  are  very  few  families 
but  have  animal  food  at  least  once  a  day.     Copious  water  supply  to  tene- 
ments ensures  all  facilities  for  cleanliness ;  and  public  baths  are  accessi- 
ble to  all  at  a  moderate  rate.     A  glance  at  the  attire  of  our  industrial 
classes  on  a  Sunday,  gives  us  volumes  of  proof  of  the  comparatively  easy 
circumstances  by  which  they  are  surrounded.     What  might  have  been 
anticipated  a  priori  from  their  superior  conditions  is  confirmed  by  prac- 
tical observation,  viz.,  that  our  industrial  classes  exhibit  a  better  general 
health,  a  robust  appearance,  and  none  of  those  excessive  forms  of  nutri- 
tive  derangement  which   are    comprised  under  the  collective  term    of 
strumous   disease.      The   contrast  existing  for   instance    between  the 
populations  of  New  York  and  Vienna  can  scarcely  be  overdrawn.     In 
the  Austrian   metropolis  almost  every  person  one   meets  looks  sallow, 
anemic,  attenuated,  physically  impoverished,  aHflictcd  with  swellings,  ulcer- 
ations, and  cicatrices  of  the  cervical  glands,  of  which  in  our  midst  there 
is  hardly  a  trace. 

The  comparison  to  which  I  have  drawn  your  attention,  gentlemen,  is 
between  Europe  and  the  United  States,  with  which  I  am  best  acquainted. 
Whether  my  remarks  apply  equally  to  your  prosperous  Provinces,  you  can 
decide  best, 


Notwithstanding  the  superior  advantages,  facilities,  and  prosperity  of 
our  industrial  classes,  and  notwithstanding  the  fact  that  scrofiilosis  in 
general  has  found  amongst  them  but  a  limited  ground  of  development, 
we  meet,  at  least  in  the  Northern  States,  with  numerous  cases  of  articular 
diseases  for  which  constitutional"  causes  cannoo  be  assigned.      What 
therefore  is  plausible  for  Europe  is  inadmissible  with  us,  and  this  very 
circumstance  was  the  first  shock  which  unsettled  my  belief  in  the  theory 
of  strumous  causation.     In  defence  of  the  old  theory  it  may  bo  urged 
that  tuberculosis  prevails  in  the  United  States,  and  satisfactorily  accounts 
for  the  occurrence  of  joint  diseases.     Such  an  argument  can  not  be  ac- 
cepted as  tenable,  though  the  facts  appropriated  as  premises  may  be  con- 
ceded.    For  it  so  happens  that  tuberculosis  is  met  :with  North  and  South, 
and  apparently  much  more  frequently  in  the  latter.     Among  the  negroes 
of  the  South,  for  instance,  glandular  affections  are  quite  common  and 
easily  accounted  for  by  their  principal  vegetable  diet  and  hygienic  indif- 
ference.    If  therefore  the  proposition  be  correct  it  will  follow  that  joint 
diseases  are  more  frequent  in  the  South  and  especially  amongst  negroes 
than  in  the  Northern  section  of  the  country.     This  is  however  not  the 
case  :  on  the  contrary  the  further  one  proceeds  South  the  less  he  meets 
with  articular  diseases ;  and  according  to  the  statements  of  competent 
surgeons  of  that  region,  they  become  perfect  rarities  near  the  Bay  of 
Mobile,  the  Gulf  of  Mexico,  and  the  West  Indies.     But  irrespective  of 
this  geographical  limitation  of  joint  diseases,  we  have  a  right  to  demand 
ocular  demonstration  of  the  tubercular  dejjosit  alleged  to  be  the  corpus 
delicti.     They  are  very  few  physicians  who  pretend  to  have  seen  tubercle 
in  the  affected  structures.  Thus,  for  instance,  Professor  Gross,  who  is  one 
of  the  warmest  advocates  of  the  theory  of  tubercular  causation,  owns  that 
he  has  never  met  with  tubercular  depositiotis  in  joints.     lie  finds  sufl5,ci- 
ent  evidence  for  his  opinion  in  the  fact  that  a  patient  dies  from  tubercu- 
losis after  having  suffered  from  joint  disease.     This  sort  of  logic  must 
pass  for  what  it  is  worth.     It  has  never  converted  me.     For  by  the  same 
reasoning  we  might  come  to  the  conclusion  that  a  furunculus,  a  parony- 
chia, or  a  fracture,  happening  to  a  consumptive  patient,  are  of  a  co-ordinate 
character  with  tuberculosis  of  the  lungs. 

Gentlemen,  I  hare  submitted  to  your  mature  consideration  my  doubts 
as  to  the  correctness  of  the  time-honoured  and  prevailing  opinion  of  stru- 
mous and  tubercular  causation.  All  I  can  desire  of  you  is  to  look  upon 
my  arguments  as  suggestive.  For  ray  part  I  have  bid  adieu  for  ever  to 
the  old  theory  as  an  unsafe  guide. 

Now  if  the  facts  adduced  are  true,  and  my  reasoning  consistent  with 
them,  and  if  I  have  made  out  a  clear  case  against  the  strumous  or  tubercular 


8 


causation  of  joint  diseases,  it  follows  that  there  must  be  causes  other  than 
those  heretofore  assigned.  To  find  them  out  and  to  prove  them  as  such 
will  be  "  the  next  business  in  order." 

I  have  already  observed  that  about  ninety  per  cent  of  all  articular 
aifections  fall  upon  the  period  of  infantile  development.  The  proportion 
is  however  very  different  in  diflFerent  ages  of  childhood.  An  aiticular 
disease  is  certainly  a  rarity  among  infants, — we  seldom  see  it  before  the 
expiration  of  the  third  year.  From  that  age  upwards  to  the  fifth  vear, 
these  affections  become  more  numerous  and  attain  perhaps  their  highest 
numerical  proportion  at  the  sixth.  Then  they  commence  to  diminish 
gradually,  and  at  about  the  tenth  year  they  are  reduced  to  but  few  recent 
cases.  Towards  puberty  these  are  probably  as  rare  as  during  the  infantile 
period.  I  "jeed  not  state  that  these  facts  are  based  upon  a  careful  statis- 
tical record  of  my  own,  and  are  borne  out  by  the  experience  of  well  em- 
ployed surgeons.  I  think  it  is  apparent  that  the  strumous  theory  does 
not  oflFer  a  satisfactory  explanation  of  these  facts,  for  the  prevalence  of 
the  disease  is  not  supposed  to  be  restricted  to  any  particular  period  of  child- 
hood. We  must  therefore  look  for  a  more  consisteint  explanation.  The 
period  of  infancy  is  that  of  special  parental  protection.  The  child  is  mostly 
under  direct  charge  of  the  mother  or  nurse,  independent  locomotion  not 
having  then  commenced.  The  second  and  third  year  of  infantile  life  en- 
joy less  or  more  the  same  protection  against  accidents  and  injuries.  With 
the  fourth  year  a  new  epoch  commences.  The  child  is  curious  and  in 
quisitive ;  it  wishes  to  examine  and  to  touch  everything ;  it  climbs  upon 
chairs  and  tables ;  it  trusts  to  its  own  guidance  and  escapes  from  the 
protecting  eye  of  its  mother ;  and  it  is  thus  exposed  to  all  sorts  of  falls 
and  mishaps.  With  advancing  age  and  knowledge  of  its  surroundings 
the  child  becomes  more  appreciative  of  danger,  and  more  careful  and 
timorous  in  its  ventures.  At  a  later  period,  when  judgment  and  pru 
dence  assume  their  sway,  accidents  and  particularly  falls  become  of  i'arer 
occurrence.  Reasoning  from  these  facts  I  cannot  but  conclude  to  regard 
traumatic  injuries  as  the  sufficient  cause  of  joint  diseases  during  child- 
l\ood. 

With  this  suppo-ition  coincides  a  cordon  of  additional  facts  equally 
demonstrative,  viz : 

1.  Joint  diseases  are  not  limited  to  any  particular  class  of  the  popula- 
tion, Yior  to  cities;  on  the  contrary  they  occur  amongst  all  classes  of 
society  and  in  agricultural  districts  as  well  as  in  the  densely  populated 
foci  of  industry. 

2.  Joint  diseases  conform  to  certain  latitudes. 

3.  Certain  joints  are  more  often  afiected  than  others. 


■; 


; 


4.  Boys  are  more  subject  than  girls,  and  sanguine  and  impulsive  chil- 
dren more  than  phlegmatic  and  indolent. 

5.  We  rarely  fail  to  trace  the  attack  to  traumatic  antecedents. 

6.  Constitutional  treatment  per  se  has  proved  of  no  avail  in  articular 
affections. 

7.  In  fine,  positive  results  follow  the  exclusive  local  treatment  of  these 
lesions. 

At  2  I  do  not  mean  to  imply  that  climate  exercises  any  direct  or  speci- 
fic influence  upon  the  numerical  distribution  of  articular  diseases,  not- 
withstanding the  undeniable  facts  previously  adduced.  But  inasmuch  as 
the  temperament,  usages,  diet,  domestic  habitations,  tastes,  employments, 
&c.,  of  the  inhabitants  differ  according  to  latitude,  we  may  be  justified  in 
speaking  thus  of  the  generative  causes  of  disease.  In  comparing  there- 
fore the  Northern  and  Southern  States  of  the  American  Union  we  notice 
differences  in  this  respect  most  material  in  their  ulterior  pathological  con- 
sequences. The  temperament  of  the  purely  Southern  people  is  less  sanguine 
and  excitable  than  that  of  their  Northern  compatriots.  The  calmness  of 
the  Southern  man  is  the  result  of  his  climatic  constitution,  and  is  in  every 
respect  natural,  whereas  the  imperturbability  of  the  New  Englander  is  the 
effect  of  incessant  social  and  religious  discipline.  The  diet  in  one  section 
is  greatly  farinaceous,  in  the  other  more  nitrogenous.  The  habitations 
of  the  one  are  spacious  but  low,  whereas  the  other  dwells  in  four  story 
buildings.  There  the  streets  and  the  environs  of  dwellings  are  left  as 
nature  provides ;  here  they  are  paved  and  improved  in  various  ways  with 
hard  surfaces.  Ease  has  pervaded  society  in  the  South,  whereas  ours 
has  been  marked  by  constant  bustle,  expansion,  restless  and  ambitious 
strife  and  collision  of  interests.  Our  employments  are  greatly  those  of  a 
commercial  and  manufacturing  people,  theirs  are  those  of  an  agricultural 
community.  In  other  w6rds  our  pursuits  engender  toil,  emulation  and 
egotism,  while  the  ircondition  is  simple,  calm,  and  primitive.  The  same 
contrast  exists  less  or  more  between  the  inhabitants  of  cities  and  agricul- 
tural districts.  What  bearing,  you  may  wonder,  have  these  differences 
upon  the  statistics  of  joint  affections  ?  Simply  this  that  a  Northern  child  is 
more  impulsive,  ambitious,  and  quarrelsome,  beci.  -le  he  is  confined,  restrict- 
ed in  space,  imposed  upon  and  brought  into  collision  with  other  children. 
His  animal  diet  renders  him  stronger  and  more  irritable.  Hence  his  lia- 
bility to  casualties.  Again  a  fall  from  a  high  staircase,  or  from  a  horse, 
waggon,  fence,  &c.,  to  a  hard  side-walk,  pavement  or  ice  occasions  more 
serious  effects  than  the  same  fall  upon  soft  ground. 

At  3  it  is  to  be  noted  that  among  all  joint  diseases  those  of  the  knee 
are  most  numerous ;  next  in  number  come  those  of  the  hip  joint ;  next 


i^; 


le 


!  ■' 


I'!! 

M 

.hi 


is; 


those  of  tho  bones  and  joints  of  the  spine ;  then  those  of  the  elbor ; 
then  those  of  the  tibio-tarsal  articulation,  &c.  These  well  known  and 
acknowledged  facts  are  not  accidental  and  the  old  theory  fails  to  account 
for  them. 

It  has  always  been  alleged  that  strumous  discnse  has  particular  affinity 
for  the  spongy  and  reticular  structure  of  bones.  If  this  be  so,  the 
tarsal,  carpal,  and  vertebral  bones  should  engender  the  disease  more 
readily  than  any  other  portion  of  the  skeleton.  Yet  as  we  have  seen 
the  numerical  preponderance  happens  at  the  knee  and  hip  articulations, 
both  these  joints  being  more  than  any  other  exposed  to  injury  by  falls, 
blows,  and  other  accidents. 

The  proposition  under  the  heading  4  needs  no  special  comment.  The 
fact  that  boys  are  more  subject  than  girls  to  articular  affections  must  be 
accounted  for  by  their  greater  exposure  to  injuries.  It  is  incompatible 
with  the  theory  of  strumous  causation,  because  girls  are  more  exposed 
than  boys  to  the  causes  of  that  disease.  At  proposition  5  it  is  worthy 
of  recollection  that  at  certain  periods  of  childhood  accidents  are  of  very 
common  occurrence,  though  they  are  generally  disregarded  as  causes  of 
disease,  unless  they  immediately  eventuate  in  great  pains,  contusions, 
wounds  or  fractures.  The  proof  of  connection  is  sometimes  difficult, 
because  weeks  and  months  may  elapse  before  the  pathological  effects 
clearly  manifest  themselves.  In  rare  cases  one  follows  the  other  so 
closely  that  the  mutual  relation  is  patent  and  unmistakeable.  That 
apparently  slight  injuries  may  suffice  to  lead  to  grave  consequences,  I 
have  had  frequent  opportunities  of  observing-  Allow  me  to  relate  but 
two  instances  in  exemplification. 

A  little  girl  fell  backward  flat  upon  the  sidewalk.  She  immediately 
experienced  violent  pain  at  a  certain  portion  of  the  spine,  and  had  to  be 
f  \rried  home.  I  saw  her  soon  after  the  fall.  One  of  the  spinous  pro- 
cesses (the  5th  dorsal)  not  only  projected  perceptibly,  but  was  painful  to 
the  touch.  The  advice  to  keep  the  patient  in  the  recumbent  posture 
for  at  least  three  months  was  followed  but  for  a  short  time,  and  the  child 
was  permitted  to  resume  locomotion.  At  the  end  of  six  weeks,  during 
which  time  the  dorsal  protrusion  had  noticeably  increased,  I  was  again 
invited  to  see  the  case.  The  little  girl  was  then  suffering  from  intense 
pleuritis  of  the  left  side,  which  eventuated  within  three  days  in  copious 
exudation  into  the  pleural  cavity  with  dislodgment  of  the  heart.  Death 
soon  ensued.  • 

The  view  I  held  and  expressed  was  that  the  recent  disease  was  on- 
nected  with  the  fracture  of  the  spine ;  that  most  probably  an  abscess 
had  formed  at  the  injured  point  in  the  column,  and  had  discharged  its 


11 


contents  into  the  pleural  sac.  The  father,  in  order  to  relieve  his  mind 
from  the  indirect  imputation  of  neglect,  repressed  his  aversioa  to  an 
autopsy.  I  need  not  assure  you,  gentlemen,  that  my  diagnosia  was  in 
every  particular  verified.  There  was,  indeed,  a  fracture  of  the  fifth 
dorsal  vertebra,  though  of  very  limited  extent,  a  mere  chipping  off-  of  a 
wedge-shaped  fragment  still  connected  with  the  next  lower  interver- 
tebral fibro-cartilage.  There  was  next  an  ab^oeps  in  front  of  the  frac- 
ture and  beneath  the  periosteum,  with,  as  it  were,  two  compartments,  one 
on  either  side  of  the  spine,  communicating  through  tlie  fracture.  The 
left  compartment,  the  larger  of  the  two,  had  effected  a  perforation  into 
the  left  pleural  cavity.  *  Besides  this,  disintegrations  of  bone,  cartilage, 
and  adjacent  structures  in  general  occupied  the  affected  locality. 

The  other  patient  was  a  middle-aged  man,  a  music  teacher,  of  German 
extraction.  When  under  the  temporary  influence  of  liquor,  he  fell  from 
an  elevation  of  about  five  feet,  and  struck  violently  the  internal  circum- 
ference of  his  right  knee  joint.  The  intense  pain  that  set  in  forthwith, 
soon  sobered  him,  and  impressed  him  strongly  with  the  apprehension  of 
grave  injury  to  the  articulation.  A  physician  was  immediately  called, 
but  failed  to  discover  ony  injury.  I  saw  the  patient  the  third  day  after 
the  accident.  There  were  no  superficial  traces  left  by  the  fall.  The 
articulation  was  hot,  swelled,  flexed,  and  extremely  tender  to  the  touch. 
From  time  to  time,  spastic  oscillations  appeared,  and  terrified  the  patient, 
who  was  pale  and  dejected  from  w'ant  of  food  and  rest.  I  placed  him 
under  chloroform,  extended  the  extremity,  and  secured  the  position  by 
appropriate  appliances.  The  trouble  yielded  without  any  further  treat- 
ment ;  and,  for  aught  I  know,  the  patient  recovered  from  an  attack  that 
might  have  permanently  affected  the  articulation. 

The  interval  of  time  between  cause  and  effect,  is,  after  all,  more  ap- 
parent than  real.  Many  cases,  especially  those  of  affections  of  the  spine, 
commence  in  so  insidious  a  manner,  and  the  initiatory  symptoms  are  so 
general  and  indefinite,  as  to  be  excusably  misinterpreted  not  only  by  the 
parents,  but  even  by  the  professional  attendant.  Among  other  cases  of 
the  kind,  I  remember  one  in  particular,  which  had  puzzled  the  physicians 
for  a  number  of  months,  until  a  correct  diagnosis  was  obtainefd. 

The  patient  is  a  little  boy  of  fine  organisation,  of  a  most  impressible 
and  active  nervous  system.  His  agility  and  daring  even  to  this  day  are 
extraordinary,  notwithstanding  the  conspicuous  posterior  curvature  which 
has  gradually  become  establislied.  He  may  have  been  five  years  old,  or 
thereabouts,  when  he  sustained  a  fall  from  a  fence  six  feet  high,  causing 
at  the  time  considerable  alarm  to  him  and  his  parents.  But  no  percep- 
tible disturbance  of  his  health  immediately  following,  all  fears  were  dis- 


12 


missed  and  forgotten:  A  few  weeks  after  the  occurrence,  the  patient 
exhibited  signs  of  general  ailment,  decrease  of  appetite,  pallor,  weakness, 
disturbed  rest,  irritable  temper,  and  indisposition  to  join  in  the  frolics  of 
his  playfellows.  Occasionally  the  pulst-  became  accelerated,  with  con- 
temporaneous thirst  and  increase  of  temperature.  He  complained  of  a 
transient  pain  in  the  stomach.  His  alvine  evacuations  were  sluggish, 
badly  mixed,  dry,  of  light  colour,  and  offensive  odour.  The  abdomen 
was  often  distended  with  gas.  The  urine  was  pale,  aud  deposited  a 
whitish  sediment.  These  symptoms  prevailed  for  months  without  ma- 
terial change.  The  diagnosis  of  an  ''affection  of  the  liver"  was  not 
without  plausibility,  inasmuch  as  that  organ  had  become  enlarged  in  all 
its  diameters.  At  the  end  of  the  eighth  month,  frequent  and  painful 
hiccough  was  observed,  and  tenderness  of  the  back  became  manifest  on 
motion  of  the  spine.  In  fine,  his  gait  became  awkward,  and  the  move- 
ments of  his  body  restrained  and  stiff.  He  craved  for  rest  and  support, 
which  he  obtained  by  placing  his  elbows  on  suitable  objects,  and  his  head 
upon  the  palms  of  his  hands.  Ten  months  after  the  accident  my  services 
were  called  into  requisition.  At  this  juncture  it  was  easy  enough  to  re- 
cognize the  nature  of  the  complaint.  The  marked  prominence  of 
several  spinous  processes  at  the  thoraco-lumbar  region  of  the  spine  ren- 
dered the  diagnosis  both  transparent  and  conclusive.  To  the  experienced 
practitioner,  it  may  seem  surprising  that  the  diagnosis  was  not  sooner 
accomplished,  and  the  disease  of  the  spine  arrested  by  appropriate  means. 
The  entire  train  of  symptoms  pointed  at  a  local  lesion  of  progressive  ten- 
dency:  and  a  searching  examination  could  scarcely  have  failed  to  reveal 
the  locality  of  the  affection.  Nevertheless  when  we  recollect  the  difl&cul- 
ties  in  the  premises,  the  aversion  of  children  to  manual  examination,  the 
disinclination  of  parents  to  see  their  offspring  thoroughly  handled  by  the 
surgeon,  and  last  but  not  least  the  limited  field  of  general  practitioners 
for  fully  observing  and  becoming  conversant  with  these  insidious  cases, 
we  will  be  sparing  in  our  censure  even  if  it  should  be  warranted.  It 
cannot  be  denied  that  in  the  case  submitted,  there  was  an  uninterrupted 
connection  between  the  accident  and  the  subsequent  disease,  I  have 
made  the  same  observation  in  many  cases  that  have  come  under  my 
charge  and  have  no  doubt  that  other  observers  have  the  same  experience. 
Nevertheless  I  am  far  from  denying  that  joint  diseases  may  arise  from 
constitutional  disorder  likewise.  But  according  to  my  clinical  researches 
their  number  is  proportionately  insignificant.  In  cases  of  this  character 
we  find  originally  more  than  one  joint  affected,  though  the  disease  may 
eventually  fix  itself  upon  one  articulation.  This  appertains  more  parti- 
cularly to  rheumatism,  gout,  and  especially  to  pyemia.     When  on  the 


13 


i 


other  hand  but  one  joint  suflfers  from  the  beginning  to  the  end,  and  the 
constutional  symptoms  supervening  are  in  conformity  with  the  inevit- 
able reaction  of  the  local  process  upon  the  general  system,  then  it  is 
rational  to  infer  that  the  local  aflfection  is  of  strictly  local  causation. 

Every  candid  practitioner  will  agree  with  the  aphorism  enunciated 
under  6.  It  is  certainly  a  simple  fact  that  the  anti-scrofulous  treatment 
of'joint  diseases  has  disappointed  both  him  and  his  patients.  My  own 
clinical  training  coincides  with  that  period  in  which  the  old  etiological 
views  held  unbounded  sway.  They  consequently  regulated  my  action 
at  the  bedside.  I  followed  with  full  confidence  and  scrupulous  exacti- 
tude the  doctrines  of  my  distinguished  preceptors  Rust  and  Von  Graefe. 
I  coveted  cases  of  this  class,  which  seemed  to  be  tacitly  alighted  by  the 
more  experienced  members  of  the  profession.  But  all  my  efforts  were  in 
vain.  I  accomplished  no  material  change  that  could  have  been  claimed 
as  the  result  of  devoted  services.  My  cases  took  the  usual  course  to 
complete  obliteration  of  the  respective  joints, — malposition  of  the  affect- 
ed extremities,  suppuration,  caries,  exhaustion  and  death.  Nay  more,  I 
had  the  mortification  to  perceive  that  I  could  but  rarely  control  the  in- 
tense pain  usually  attendant  upon  such  cases.  Similar  admissions  have 
been  made  by  other  experienced  practitioners,  and  I  am  led  to  believe 
that  the  negative  results  of  anti- scrofulous  treatment  of  joint  diseases  is 
now  generally  conceded  by  that  portion  of  the  profession  whose  opinion 
has  any  value. 

In  the  seventh  aphorism,  I  broadly  assert  without  fear  of  contradicion 
that  in  the  treatment  of  joint  diseases,  local  appliances  scarcely  ever  fail 
of  modifying  or  subduing  the  morbid  process.  For  the  last  ten  years  I 
have  held  these  views,  and  practically  tested  them  at  the  bed  side ;  and  I 
can  candidly  and  most  emphatically  assure  you  that  the  results  thus  at- 
tained have  been  most  satisfactory  in  ever  particular.  In  but  few  cases 
have  I  ever  had  any  need  for  constitutional  remedies.  Most  of  them 
yielded"  readily  to  local  means ;  and  with  the  local  improvement  the  pre- 
vailing constitutional  disturbances  subsided.  When  thus  rest  and 
appetite  were  insured,  the  patients  increased  in  weight,  and  rapidly  im- 
proved in  appearance  and  feeling.  I  need  hardly  state  that  my  thera- 
peutic views  on  this  point  were  slighted  for  a  number  of  years  by  those 
men  to  whom  the  profession  look  up  for  precept  and  example.  But  when 
Dr.  Davis'  portative  extension  apparatus  became  generally  known,  the 
professional  mind  underwent  a  material  change  and  then  turned  its  at< 
tention  to  the  subject.  A  few  years  ago  the  New  York  Academy  of 
Medicine  discussed  the  subject  of  hip  disease  at  successive  meetings. 
Most  of  those  who  participated  in  the  discussion  admitted  in  emphatic 


■'151 


14 

terms  the  therapeutic  efficacy  of  that  instrument,  retaining  at  the  same 
time  the  old  tubercular  theory  of  causation.  Nobody  seemed  to  notice 
the  contradiction  between  theory  and  practice,  and  it  was  then  and  there 
that  my  views  gained  the  ascendency.  I  simply  stated  on  that  occasion 
that  but  one  could  be  right.  **  If  hip  disease  were  the  consequence  of 
strumous  invasion,  a  portative  extension  of  but  few  pounds  could  have 
no  eflFect  whatever  in  relieving  or  cur.ng  that  complaint ;  .and  if  it  actu- 
ally had  the  effect  alleged,  it  would  be  the  most  undeniable  proof  against 
the  constitutional  character  of  the  disease."  Ti  attempt  to  refute  my 
logic  was  as  feeble  as  it  was  unsuccessful,  and  from  that  date  it  may  be 
said  that  the  new  theory  was  admitted  to  scientific  citizenship.  I  shall 
not  on  this  occasion  enter  more  extensively  upon  the  subject,  inasmuch 
as  I  have  to  recur  to  it  when  speaking  on  the  treatment  of  articular 
diseases. 


II. 


ANATOMICAL  CHARACTER  OF  JOINT  DISEASES 


Gentlemen, — All  the  anatomical  components  of  a  joint  may  separate- 
ly and  collectively  become  diseased.  Their  morbid  susceptibility  varies 
however  in  a  material  degree.  The  articular  cartilage  occupies  obvious- 
ly the  lowest  point  in  the  scale.  In  conformity  with  its  purely  physical 
office,  it  is  elastic,  only  indifferently  organized,  and  devoid  of  nerves  and 
vessels.  Its  nutrition  is  therefore  of  a  low  order,  accomplished  chiefly 
by  transudation  and  imbibition.  Reasoning  from  these  premises  it  might 
a  priori  be  assumed  that  this  structure  possesses  but  a  trifling  suscepti- 
bility to  independent  morbid  action.  This  supposition  receives  addition- 
al strength  from  experiments  upon  animals  by  Redfern,  0.  Weber,  and 
others  who  found  thatjneither  physical  violence  nor  chemical  irritants  have 
much  lasting  effect  upon  articular  cartilage.  The  intervertebral  fibro- 
cartilages  are  of  higher  organization,  and  are  therefore  endowed  with  a 
more  decided  susceptibility  to  morbid  changes  thanjthose  of  joints.  I 
have  made  clinical  observations  to  this  effect,  and  I  have  recorded  one 
case  of  inflammatory  disintegration  of  so  striking  a  character,  that  no 
reasonable  doubt  could  be  raised  against  it.     In  advanced  diseases  of 


16 


joints  and  of  the  spine  it  is  impossible  to  determine  whether  the  cartilage 
or  some  other  structure  has  been  first  affected.  The  destruction  is  com- 
monly so  general  as  to  leave  no  room  for  speculation.  I  am  inclined  to 
believe  that  the  cartilage  suffers  but  rarely  from  primary  lesion,  but  that 
it  often  participates  in  the  affection  of  the  subjacent  bone,  and  is  subject 
to  disintegration  from  purulent  maceration. 

That  the  cartilage  displays  but  a  passive  character  in  the  so  called  ar- 
thritis de/orm,ans  progressiva  is  now  well  understood. 

The  synovial  lining  is  a  sort  of  intermediate  structure.  It  does  not 
I'  aform  to  serous  membranes  with  which  it  has  heretofore  been  classed. 
Its  greater  thickness,  albuminous  secretion  and  layered  epithelium  bring 
it  nearer  to  the  anatomical  structures  of  mucous  membranes  from  which 
it  differs  by  the  absence  of  mucous  follicles.  The  Haversian  glands  are 
no  glands  at  all,  but  synovial  insaculations  filled  with  fat.  Gosselin's  fim- 
briae have  thus  far  not  met  with  general  acceptance,  nor  have  their 
functions  been  fully  ascertained. 

According  to  Richet  the  healthy  synovial  membrane  is  very  vulnera- 
ble.    Injections  of  irritating  fluids  into  the  joints  of  animals  are  prompt- 
ly followed  by  great  vascularity,  hyperemia,  pinkish  and  purple  disclora- 
tion,  and  opacity  of  the  synovial  lining  with  serous  infiltration  of  the 
adjacent  connective  tissue.     The  vessels  frequently  cluster  around  the 
articular  cartilage,  sand  by  anastomosis  form  as  it  were  a  continuous 
wreath  from  which  returning  twigs  branch  over  the  margin.     Occasion- 
ally the  synovial  membrane  becomes  so  oedematous  and  pouched  as  to 
circumvallate  the  cartilage  as  chemosis  does  the  cornea.     By  degrees  the 
entire  surface  of  the  joint  becomes  roughened  and.  granulated.     The 
epithelium  luxuriates  and  is  converted  into  pus  corpuscles  which  are  suc- 
cessively thrown  off  and  the  articular  cavity  is  filled  with  purulent  fluid 
(pyarthrosis) ;  similar  pathological  changes  may  often  be  observed  to 
follow  penetrating  wounds,  with  this  difference  however  that  in  the  be- 
ginning the  synovial  fluid  forms  a  material  constituent  item  of  the  dis- 
charge, and  reappears  occasionally  when  the  process  is  subsiding.     From 
these  experiments  it  would  seem  that  the  synovial  lining,  notwithstand- 
ing its  destitution  of  nerves  and  vessels,  is  highly  susceptible  to  morbid 
action  of  the  peracute  type.     But  clinical  experience  has  collected  many 
facts  to  the  contrary.     Thus,  for  instance,  some  penetrating  wounds  close 
by  first  intention  without  inconvenience  to  the  injured  joint,  although 
blood  may  have  been  left  behind  and  air  may  have  entered.    Many  a  time 
have  I  performed  articular  puncture  by  trochar  and  knife  without  a  single 
bad  effect,  having  of  course,  as  much  as  possible,  prevented  the  entrance  of 
air. 


i 


16 


1 1 


In  hydrarthrosis,  Nekton  has  freely  resorted  to  injection  of  iodine, 
and  others  have  followed  his  example.  According  to  the  i  statements, 
only  a  moderate  reaction  usually  ensues.  Free  incisions  into  affected 
joints  have  been  made,  checking  the  disease,  and  saving  extremities. 
Amputations  in  contiguity  leave  always  a  portion  of  the  joint,  and  some 
surgeons  prefer  these  operations  on  account  of  better  statistical  returns. 
These  facts  constitute  a  formidable  offset  to  the  rule  based  upon  Eichet's 
investigations.  It  is  not  unlikely  that  chemical  irritants,  applied  to  a 
healthy  articular  surface,  will  readily  lead  to  a  rapidly  advancing  synovitis, 
and  repeated  applications  of  this  sort  will  bring  about  those  progTcssive 
changes,  of  which  Richet  gives  so  graphic  an  account.  But  it  does  not 
follow  that  atmospheric  air  would  give  rise  to  the  same  disturbances. 
According  to  my  experience,  the  dangers  of  penetrating  wounds  have 
been  altogether  overrated.  In  the  course  of  the  last  few  years  I  have 
attended  a  considerable  number  of  cases,  many  of  them  formidable, 
and  have  in  every  instance  obtained  satisfactory  results.  This  may 
have  been  due,  in  part,  to  the  healthy  condition  and  tolerably  good  sur- 
roundings of  my  patients,  but  not  les^  to  the  more  appropriate  treatment 
that  has  found  its  way  into  surgery.  From .  clinical  observation,  how- 
ever, I  have  received  the  impression  that  the  synovial  membrane  has  a 
dangerous  afl5.nity  for  disturbing  causes  of  a  constitutional  character. 
Rheumatism,  syphilis,  and  pyemia,  in  particular,  select  this  structuro  in 
preference  to  the  other  components  of  joints.  Of  late  much  has  been 
said  and  written  about  tubercular  synovitis ;  Foerster  has  never  met  it, 
and  he  is  certainly  no  superficial  observer.  Nor  have  I  had  an  oppor- 
tunity of  examining  a  single  case  of  this  description,  although  I  may 
say,  without  boasting,  that  I  examine  as  many  cases  of  joint  diseases  u  j 
any  well-employed  surgeon.  If,  moreover,  tubercular  synovitis  is  of  a 
nature  similar  to  that  of  tubercular  meningitis,  it  means  little  more  than 
initiatory  changes  in  the  subsynovial  tissue  towards  suppuration, — 
namely,  hyperplasy  of  connective  tissiie.  Still  I  do  not  pretend  to  ex- 
press a  conclusive  opinion  upon  what  has  so  sedulously  evaded  my  most 
inquisitive  pursuit. 

Some  authors  believe  that  the  synovial  lining  suffers  most  severely 
from  incidental  traumatic  injuries.  I  beg  to  dissent  from  this  opinion. 
If  both  constitutional  and  local  causes  expend  their  force  upon  the 
synovial  membrane,  all  joint  diseases  would  resolve  themselves  into 
synovitis,  and  the  other  components  would  pass  clear  of  primary  disease. 
Both  clinical  aim- anatomical  observation  refute  views  so  untenable. 
Most  injuries  befall  the  prominent  portions  of  joints — the  bones  and 
their  periosteal  coverings,  because  they  are  most  exposed,  and  because 


17 


lG 
,0 


they  oflFer  static  resistance.  And  even  if  the  synovial  sac  comes  in  for 
its  lesser  share,  the  consequences  cannot  be  beyond  speedy  redress. 
Inflammation,  excited  by  a  transient  cause,  would  soon  terminate  in 
copious  secretion  of  synovial  fluid ;  and  this,  in  turn,  would  be  absorbed. 
A  moderate  admixture  of  purulent  elements  would  not  materially  afiect 
final  resolution.  Permanent  disintegration  of  the  synovial  lining,  or  of 
the  other  constituents  of  the  joint,  could  not  well  be  ascribed  to  a  com- 
paratively trifling  and  transient  cause. 

In  the  anatomical  consideration  of  joint  diseases,  there  has  not  yet 
been  assigned  to  the  periosteum  that  importance  which  it  so  fully 
deserves.  In  the  first  place,  the  periosteum  continues  as  part  of  the 
joint  from  one  bone  to  the  other,  constituting  the  so-called  fibrous  capsule. 
Next,  it  partly  covers  the  epiphyses  and  condyles  of  the  cylindrical  bones, 
and  consHtutes  the  means  of  their  maintenance,  growth,  and  develop- 
ment. From  the  first  anatomical  relation  results  the  direct  transmission 
of  disease ;  and  upon  the  other  depends  the  structural  condition  of  an 
essential  articular  component. 

In  the  course  of  m^  surgical  practice,  I  have  observed  cases  of  joint 
disease  that  could  be  traced  to  no  other  cause  than  traumatic  periostitis. 
Some  of  them  involved  both  limb  and  life.  I  will  relate  one  in  striking 
exemplification.  A  lad  of  thirteen  years,  in  perfect  health,  an*!  without 
any  noticeable  morbid  diathesis,  was  struck  with  a  medium-sized  cobble- 
stone at  the  middle  of  the  tibial  crest.  Judging  from  the  lesser  age  of 
the  boy  who  aim?*:!  the  blow,  from  a  distance  of  about  twelve  yards,  the 
force  could  -^ot  have  been  very  considerable.  The  impression  upon  the 
leg  was  apparently  insignificant.  The  pain  was  trifling,  and  no  bruise  or 
indentation  appearing,  the  patient  paid  no  attention  to  the  injury  during 
the  succeeding  five  or  six  days,  and  continued  at  his  duty  as  an  errand- 
boy.  Subsequently  he  found  locomotion  impracticable,  his  leg  having 
become  painful  and  so  swollen  that  he  could  not  get  'ais  boot  on.  A 
physician  was  now  sent  ^.'y  the  father  of  the  offender.  Tiie  attendant 
failed  to  penetrate  the  nature  of  the  lesion.  Thus  twelve  days  more 
were  irretrievably  lost  in  paltry  applications.  When  better  advice  was 
finally  obtained,  the  disease  had  made  considerable  advance,  demanding 
more  than  anything  else  extensive  and  deep  incisions.  These  wr  not 
resorted  to  to  a  sufficient  extent.  I  was  called  in  at  about  the  sixth  week 
after  the  accident,  and  found  the  patient  in  a  most  critical  situation,  and 
fearfully  reduced.  Then  no  alternative  to  amputation  remained,  for  the 
limb  and  the  corresponding  knee-joint  were  so  extensively  and  irrecover- 
ably diseased  that  no  attempt  at  saving  the  .limb  could  be  entertained. 
The  specimen  revealed  the  following  state  : — Almost  entire  destruction 


1  :^; 


t    I 


\i 


;  'J 


18 


of  periosteum  of  the  tibia,  exposure  ami  discoloration  of  that  bone  ;  the 
remaining  portion  of  the  periosteum  towards  the  knee-joint  undermined, 
allowing  the  passage  of  a  stout  probe  inlo  the  articular  cavity  at  the 
lower  insertion  of  the  fibrous  capsule.  The  latter  was  itself  perforated 
by  ulceration  at  the  external  and  posterior  walls,  and  the  joint  exhibited 
the  pathological  changes  of  advar  -"^d  pyarthrosis.  The  patient  had  a 
speedy  recovery,  and  has  for  the  last  six  years  enjoyed  the  most  un- 
qualified health.  Now,  gentlemen,  this  case  proves  indeed  more  than  I 
have  claimed.  Here  a  lad  in  perfect  health  receives  nn  injury  at  a  point 
remote  from  the  knee-joint,  which  lights  up  an  inflammation  of  the  perios- 
teum. Not  being  recognised  and  controlled,  the  inflammation  proceeded 
to  suppuration  ;  the  matter  spread  below  the  periosteum  in  every  direc- 
tion, until  it  reaches  the  capsular  apparatus,  and  finds  access  to  the 
joint.  As  soon  as  the  diseased  structures  are  removed,  the  patient 
regains  his  former  health  and  strength,  precluding  every  suspicion  what- 
ever of  constitutional  disease.  This  is  certainly  a  clear  case  of  traumatic 
periostitis,  involving  an  articulation ;  and  the  chain  of  evidence  is  con- 
tinuous from  the  very  starting  point  to  the  finale.  This  case  is  by  no 
means  as  isolated  and  exceptional  as  might  be  supposed,  although  in 
others  the  clinical  history  may  not  always  be  found  so  plain  and 
transparent. 

The  foregoing  belongs  to  a  class  of  cases  that  are  generally  insidious 
and  protracted.  For  a  long  time  they  cause  but  little  inconvenience  to 
the  patient,  and  therefore  they  are  slighted  at  the  time  when  appropriate 
treatment  could  scarcely  fail  to  arrest  their  progress.  Thus  with  very 
little  change  they  pass  on  for  many  months,  until  an  acute  period  is 
reached  and  the  joint  is  found  to  be  extensively  diseased.  The  ori^nal 
traumatic  cause  is  forgotten ;  it  appeared  at  most  to  be  insignificant, 
and  in  the  estimation  of  all  parties  concerned,  could  not  have  given 
occasion  to  consequences  so  severe.  Meanwhile  the  constitution  of  the 
patient  has  materially  suffered,  the  vital  forces  arc  dep.'essod,  the  appetite 
has  become  indifferent,  weight  has  decreased,  in  fact  nutrition  has 
gradually  and  proportionally  declined,  as  the  local  disease  has  extended 
its  sway.  This  is  the  history  of  most  cases  occurring  during  childhood, 
and  it  is  this  class  that  has  been  set  down  as  the  result  of  strumous 
causation,  in  default  of  any  other  known  cause. 

Now,  gentlemen,  must  iherc  not  be  a  general  predisposition  attached 
to  the  physical  condition  of  infantile  development,  that  favors  diseases 
of  joints,  and  disappears  at  puberty  ?  No  one  seems  to  have  paid  much 
attention  to  this  query,  and  hence  the  preponderance  of  joint  affections 
in  childhood  has  remained  unaccounted  for,  up  to  this  very  day.  It  is 
still  an  enigma  unsolved. 


ce 


19 


Laying  aside  all  the  fetters  of  established  doctrines,  let  us  try  to  find 
out  some  of  the  anatomical  diflFerenccs  existing  between  the  joints  of 
children,  and  those  of  adults.  Perhaps  they  may  furnish  us  the  key  to  a 
correct  understanding  of  the  matter.  All  we  meet  is  the  cpiphysal 
contrivance  which  serves  wise  purposes  in  the  giowth  and  development 
of  the  osseous  architecture,  but  allows  the  c^uphyses  themselves  to  be 
liable  to  mechanical  derangement.  We  need  but  to  look  at  a  vertebra 
composed  as  it  is  of  seven  different  pieces  held  together  by  cartilaginous 
discs  and  periosteum.  By  this  arrangement  it  is  rendered  a  very  elastic 
body  capable  of  accommodating  itself  to  many  exigencies.  But  its 
resistance  is  limited  to  its  elasticity,  and  the  single  pieces  may  under 
certain  circumstances  become  disjointed  or  somewhat  altered  in  mutual 
relation.  Diastasis  is  a  solution  of  continuity  solely  appertaining  to  the 
period  of  childhood. 

At  an  early  stage  of  infantile  life  the  different  epiphyses  of  the  skeleton 
present  a  marked  peculiarity  in  the  mode  of  their  maiatenance,  and  there 
is  reason  to  believe  that  this  mode  partially  continues  to  within  a  short 
time  before  puberty.  Careful  injection  of  the  nutrient  vessels  of  the 
bones  of  infants  and  children,  demonstrate  pretty  clearly  that  the 
epiphysis  receives  no  vascular  complement  from  that  source.  In  fact  the 
vessels  pass  only  to,  and  not  through  the  epiphysal  cartilage.  On  the 
other  hand  the  vessels  that  enter  the  epiphysis  have  no  communication 
with  the  nutrient  artery  of  the  shaft.  They  are,  as  it  seems,  completely 
isolated  from  each  other  by  the  cartilaginous  disc.  Most  epiphyses  arc 
supplied  with  blood  from  the  periosteum,  with  which  they  are  in  part 
covered.  Those  epiphyses  to  which  the  periosteum  can  not  approximate 
closely  enougl.,  have  a  special  source  of  nutrition.  Thus  for  instance 
the  head  of  the  femur  receives  its  supply  from  a  branch  of  the  obturator 
artery  which  enters  the  notch  of  tne  acetabulum  atid  accompanies  the  so 
called  ligamentum  teres,  to  its  destination.  The  nerve  takes  the  same 
course.  A  rather  complex  mode  exists  at  the  knee  joint  through  both 
periosteum  and  the  ligamenta  cruciata.  After  the  skeleton  has  attained 
its  full  development,  a>id  the  epiphy,ses  have  become  continuous  with  their 
respective  bones,  nutrition  is  perfected  by  anastomosis  of  the  several 
vessels.  But  the  intermediate  parts  of  some  bones  seem  never  to  achieve 
a  full  share  in  nutrition,  thus  we  know  that  fracture  of  the  femc^iil  neck 
but  rarely  heals  by  bony  union.  It  is  very  necessary  that  we  become 
fully  acquainted  with  all  these  physiological  facts  as  they  servo  to  throw 
light  upon  a  field  hitherto  obscure. 

The  epiphyses  constitute  the  most  prominent  part  of  the  joints,  and  re- 
ceive most  of  the  violence  of  traumatic  injuries,  the  soft  parts  being  thus 


■mi 


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20 


,:.?'. 


in  a  measure  protected.  At  the  limited  space  of  contact  with  the  offend- 
ing force,  the  integuments  and  the  periosteum  are  contused  and  ecchy- 
mosed,  and  the  nerves  of  the  joint  less  or  more  injured.  The  integu- 
ments may  soon  recover  ;  at  any  rate  their  structural  derangement  would 
be  of  but  little  consequence.  Not  so  with  the  periosteum.  If  the  extra- 
vasation of  blood  takes  place  in  the  usual  way,  that  is  to  say  beneath  the 
latter,  it  constitutes  in  my  estimation  a  serious  trouble.  Irrespective  of 
ecchymosis,  the  eventual  cause  of  subperiosteal  suppuration,  the  very  pre- 
sence of  blood  denotes  disruption  of  the  vessels  intended  to  supply  the 
nutritive  demand  of  the  epiphysis.  The  extent  of  the  part  borne  by  in- 
juries of  articular  nerves  (sensitive  and  trophic)  in  exciting  articular 
diseases  has  as  yet  not  been  clearly  ascertained.  A  case  previously  de- 
tailed gives  strong  evidence  to  this  eflFect.  The  same  injury  to  any  other 
part  of  the  bone  might  be  comparatively  harmless,  and  would  generally 
eventuate  in  exfoliation,  because  the  nutrition  of  the  bone  depends  only 
in  part  on  the  periosteum.  It  would  seem  therefore  that  even  apparently 
trifling  contusions  at  the  epiphysis  should  be  viewed  with  deference  and 
treated  with  becoming  care.  But  if  they  give  rise  to  subperiosteal  sup. 
puration,  there  is  in  two  ways  imminent  danger  for  the  joint : — first,  by 
the  matter  spreading  below  the  periosteum  and  forcing  its  way  into  the 
articular  cavity ;  and  secondly,  by  instituting  necrobiosis  of  the  epiphysis 
in  part  or  in  toto.  The  latter  mode  is  obviously  the  more  frequent.  The 
destruction  or  detachment  of  the  entire  epiphysis  by  this  process  is  very 
rare, — more  frequently,  one  of  the  condyles  is  implicated,  enlarged^ 
osteoporotic,  and  very  tender.  From  thence  the  disease  radiates  to  the 
remaining  structures,  and  thus  the  joint  becomes  compromised.  I  have 
but  lately  exhibited  to  the  New  York  Pathological  Society,  a  specimen 
illustrating  this  process.  A  small  sequestrum  in  the  internal  condyle  of 
the  femur  was  evidently  the  proximate  cause  of  the  extensive  trouble  to 
the  joint,  amounting  to  an  almost  complete  obliteration  of  its  cavity  by 
adhesive  synovitis. 

Primary  diseases  of  the  epiphysis  are  not  of  frequent  occurrence,  and 
least  of  all  osteomyelitis. 

The  process  of  gradual  destruction  is  most  simplified  at  the  hip-joint, 
and  its  varied  phases  may  best  be  studied  there.  A  few  anatomical  re- 
marks will  be  necessary.  The  ligamentum  teres  must  be  accepted  as  a 
ligament  in  an  anatomical  point  of  view,  on  account  of  its  being  endowed 
with  a  considerable  complement  of  fibrous  structure.  Besides  this,  how- 
ever, areolar  tissue  and  fat  enter  largely  into  its  composition,  encompas- 
sing the  nerves  and  vessels  passing  to,  and  from  the  head  of  the  femur. 
No  anatomist  has  as  yet  been  able  to  demonstrate  the  office  of  the  round  liga- 


21 


mcnt.  The  head  of  the  femur  fits  so  accurately  in  the  acetabulum  that  it 
is  held  there  by  atmospheric  pressure,  or,  as  others  think,  by  cohesion.  This 
bone  may  dislocate  in  any  direction  without  the  ligamentum  teres  being 
ruptured;  it  consequently  places  no  restraint  upon  the  movements  of  the 
thigh  bone.  Some  instances  are  known  where  the  joints  lacked  it  altogether, 
without  marked  impediments  resulting.  Again  it  has  been  ruptured  in 
the  act  of  violent  dislocation  and  the  returned  head  of  the  thigh  bone 
moved  almost  to  the  same  perfection  as  before.  Thus  it  would  appear 
that  this  ligament  bears  no  part  in  the  action  of  the  hip  point.  Another 
oflSice  must  have  been  assigned  to  it.  To  all  appearance  it  acts  as  the 
protector  of  those  nerves  and  vessels  which  form  the  nutritive  apparatus 
of  the  head  of  the  femur.  Without  this  protection  the  nutrition  of  the 
femoral  epiphysis  could  not  be  effected.  Collectively  I  look  upon  the 
ligamentum  teres  therefore  as  the  essential  nutritive  appendix  of  the 
head,  and  its  destruction  during  the  epiphysal  period  as  tantamount  to 
the  destruction  of  the  head  itself.  From  the  composition  of  the  round 
ligament  a  high  degree  of  susceptibility  must  be  inferred.  In  fact,  none 
of  the  articular  components  can  bear  any  comparison  to  it  in  this  res- 
pect. Besides  the  ligamentum  teres  is  subject  to  contusion  from  violence 
to  the  gieat  trochanter,  whilst  the  thigh  is  in  the  position  of  adduction 
and  eversion.  And  upon  the  trochanter  falls  are  generally  received. 
Boyer  has  already  expressed  the  belief  that  morbus  coxarius  emanates 
from  the  round  ligament ;  but  for  want  of  pathological  facts,  he  did  not 
succeed  in  convincing  his  contemporaries.  The  scrofulous  theory  very 
soon  preponderating,  overawed  his  views,which  well  deserved  consideration. 
Perhaps  no  articulation  has  suffered  more  from  the  dogmatism  of  the 
humoralist  school  than  the  hip  joint ;  and  the  fiction  culminated  into  a 
system  in  morbus  coxarius.  There  were  explanations  in  it  for  every 
single  symptom.  Very  few  of  these  are  destined  to  survive  the  present 
<3entury.  ^ 

It  cannot  be  denied  that  morbus  coxarius  may  possibly  be  caused  by 
primary  synovitis  or  periostitis  with  subsequent  centripetal  perforations. 
But  the  majority  of  cases  must  necessarily  result  from  primary  disinte- 
gration of  the  round  ligament.  Among  the  reasons  for  this  opinion,  of 
which  I  have  already  enumerated  a  few,  stands  in  the  boldest  relief  the 
pathological  fact  that  the  round  ligament  is  invariably  destroyed  at  a 
time  when  the  remaining  components  of  the  joint  have  suffered  but 
moderate  disintegration.  Next  comes  the  striking  fact  that  the  head  of 
the  femur  is  invariably  reduced  excentrically  in  size,  and  in  a  few  excep- 
tiona!  instances  thrown  off  in  toto.  That  the  origination  and  frequency 
of  morbus  coxarius  in  childhood  has  the  closest  connection  with  the 


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epiphysal  construction  admits  of  no  doubt  in  my  mind ;  and  it  explains 
satisfactorily  the  comparative  rarity  of  this  affection  during  adult  life 
when  the  epiphysis  is  completely  united  with  the  shaft,  its  nutrition 
thereby  perfected,  and  the  liability  to  accident  lessened. 

Gentlemen,  I  shall  here  close  my  discourse  on  the  pathology  of  joint 
diseases,  and  not  inflict  upon  you  a  reiteration  of  all  that  is  said  better 
in  the  works  of  Sir  Benjamin  Brodie,  Robitansky,  Paget,  Gurlt,  and 
other  distinguished  pathologists.  Moreover,  the  practical  benefit  of  being 
thoroughly  versed  in  the  ulterior  structural  changes  attending  joint 
diseases,  is  indeed  of  questionable  value.  If  you  see  one  joint  in  the 
last  stage  of  its  malady,  you  have  seen  them  all,  so  littla  difference  be- 
tween them  is  presented.  My  chief  object  has  been  to  acquaint  you 
with  the  initiatory  changes  of  joint  diseases,  and  thus  lead  you  in  a 
practical  direction  for  the  prevention  of  their  destructive  advancement. 
But  even  in  this,  I  have  had  to  consult  brevity  and  terseness  in  order 
best  to  utilize  the  limited  time  at  my  disposal. 


III. 


CLLNICAL  CHARACTER  OF  JOINT  DISEASES. 


All  joint  diseases  have  some  symptoms  in  common.  Of  these  pain  is 
the  most  prominent ;  usually  the  first  to  appenr,  and  the  last  to  disappear. 
Clinical  observation  discerns  two  kinds  of  pain — one  emanating  directly 
from  the  diseased  structure ;  the  other  proceeding  in  a  circuitous  man- 
ner from  the  spinal  cord,  and  ?uanifesting  itself  in  parts  not  directly  con- 
nected with  the  affected  articulation. 

The  fonuer  is  known  by  the  term  of  structural  or  injlammatory  pain ; 
the  latter  as  rejlex.  The  structural  pain  varies  in  extent,  intensity,  and 
duration,  according  to  the  tissues  implicated^  and  to  the  nature  and  ex- 
tent of  the  malady.  In  some  instances  the  pain  may  occupy  but  a  small 
and  c'lcumscribed  place;  in  others  it  miy  be  diffu.«ed  over  the  entire 
articulation,  and  extend  even  beyond  it. 

its  intensity  may  vary  from  the  sensation  of  heat  and  '••jness,  to  the 
degree  of  burning,  lancinating  and  pulsating ;  and  be  eq\  lly  variable  in 
its  continuance. 

The  morbid  condition  of  the  affected  structures  does  not  always  furnish 
a  satisfactory  explanation  of  the  degree  of  pain  ;  but  too  often  one  ia  out 


23 


1 


of  keeping  with  the  other.  Thus,  for  instance,  a  mere  ephemeral  rheu- 
matic synovitis,  and  in  hysteric  affection?,  the  pain,  for  the  time  being, 
is  very  intense  and  largely  diffused,  whereas,  in  hydrarthrosis  but  little 
inconvenience  to  the  patient  arises  from  a  similar  source,  The  general 
affection  of  an  entire  articulation,  with  advanced  disintegration  of  the 
various  tissues,  may  exist  for  months,  and  yet  be  attended  with  compara- 
tively little  suffering,  whilst  on  the  other  hand,  affections  apparently 
trifling,  may  create  a  storm  of  symptoms  and  intense  agony. 

In  structural  pain  therefore,  but  a  conditional  seraiotic  importance  can 

be  attached.     In  this  respect  the  same  axiom  rules  as  in  the  healing  art 

generally — "  that  but  the  congruity  of  symptoms  is  the  base  of  diagnosis." 

Notwithstanding  all  this,  some  general  rules  can  be  recognised  as  a 

guide  at  the  bedside : 

1st.  The  structural  pain  is  commonly  proportionate  to  the  nervous  en- 
dowment of  the  tissue  affected. 

2nd.  The  pain  increases  and  diminishes  in  proportion  to  the  progress 
and  regress  of  the  disease. 

3rd.  The  pain  is  rendered  more  intense  by  false  position  of  the  articu- 
lation. 

4th.  The  pain  increases  when  the  affected  structures  become  subject  to 
centrifugal  distension  by  effusion  of  whatever  composition,  and  to  irrita- 
tion by  pus,  loose  sequestra,  and  foreign  bodies. 
5th.  The  pain  is  augmented  by  touch  and  motion. 
6th.  Whatever  induces  and  increases  pain,  hastens  tlie  advance  of  the 
articular  disease,  and  vice  versa. 

The  so  called  reflex  pain  is  obviously  of  a  neuralgic  character.  Being 
excited  by  the  local  disturbance,  the  morbid  impression  is  conveyed  to 
the  spinal  cord,  the  common  centre  of  irradiation  ;  thence  it  is  reflected 
backward  to  the  muscles  appertaining  to  the  affected  joint,  and  sometimes 
to  the  next  articulation ;  as  for  example,  the  almost  pathognomonic  pain 
at  the  knee  in  coxalgia. 

The  latter  mode  is  rather  an  exception,  and  an  isolated  clinical  fact, 
which  may  be  explained  in  this  manner :  "  that  the  same  nerve  (obturator) 
supplies  both  joints  with  sensitive  fibres,  warranting  the  supposition  of 
irradiating  in  the  closest  proximity." 

From  the  fact  that  the  reflex  pain  occurs  commonly  during  night  and 
the  sleep  of  the  patient,  it  must  be  inferred  that  the  trophic  or  ganglionic 
province  is  principally,  if  not  exclusively  involved.  But  a  few  exceptions 
have  come  to  my  notice  to  which  I  shall  refer  in  due  course.  You  are 
perhaps  aware  that  I  was  the  first  observer  of  these  reflex  pains ;  at  all 
events,  I  was  the  first  who  called  attention  to  them,  and  explained  their 


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24 

character  and  operation.  Perhaps  they  might  have  escaped  my  observa- 
tion as  well,  had  I  not  for  a  time  shared  the  same  roof  with  patients  of 
this  class,  and  had  not  thus  an  opportunity  been  afforded  me  for  study- 
ing this  singukr  symptom  in  all  its  bearings. 

One  night,  after  having  left  my  patients  profoundly  asleep  with  the 
lights  lowered,  my  attention  was  suddenly  attracted  by  a  peculiar  shriek 
emanating  from  the  sick  room.  Within  half  an  hour  the  shriek  was 
twice  repeated. 

Though  well  acquainted  with  the  different  voices  of  my  little  patients, 
I  could  not  discern  to  whom  the  cry  belonged.  It  was  in  so  peculiar  a 
note,  high,  shrieking  and  short,  commencing  with  a  full  intonation,  and 
terminating  as  abruptly.  In  entering  the  room,  I  found  everything  and 
everyone  as  quiet  as  I  had  left  them  shortly  before.  The  only  noticeable 
change  was  an  acceleration  in  the  breathing  of  one  of  the  patients. 

Whils^,  thus  contemplating  and  watching  him,  he  again  uttered  the 
same  shriek,  rose  into  a  sitting  posture,  rubbed  his  eyes,  stared  around 
with  a  terrified  expression,  and  sunk  back  upon  his  bed,  continuing  his 
scarcely  interrupted  sleep.  In  another  ten  minutes  this  scone  was  re- 
enacted,  with  almost  the  same  concomitants.  During  several  of  these 
paroxysms  I  observed  a  peculiar  quiver  of  both  the  adductor  and  flexor 
muscles  of  the  thigh.  The  rest  of  the  joint  was  evidently  disturbed  by 
it,  and  the  paiu  accompanying  the  quiver  must  have  been  of  an  agonizing 
character,  for  the  patient  automatically  grasped  the  affected  limb,  as  if  to 
arrest  the  involuntary  movement.  His  rest  for  the  balance  of  the  night 
was  disturbed  by  meanings,  and  repeated  attempts  to  changing  h'  nosi- 
tion.  I  found  the  aspect  of  the  patient  much  changed  on  the  following 
morning ;  he  looked  pallid,  haggard,and  prostrate  ;  he  was  of  morose  and 
irritable  temper,  his  pulse  excited,  and  his  appetite  indifferent.  The 
tenderness  of  his  joint  had  signally  increased.  Whilst  the  abduction 
was  more  difficult  and  painful  than  before,  the  entire  group  of  the  ad- 
ductor muscles  was  as  tense  as  if  possessed  of  tonic  spasm. 

In  continuing  my  observations  for  successive  years,  I  have  seen  this 
very  symptom  in  almost  every  aggravated  case  of  joint  disease  in  struc- 
tural affections  of  the  spine,  and  in  acute  periostitis  in  the  proximity  of 
joints.  In  all  these  cases  it  is  invariably  of  the  same  type,  though  vary- 
ing in  intensity.  The  greatest  violence  of  reflex  pains  we  observe  in 
morbus  coxarius,  and  in  affections  of  the  knee  joint. 

It  is  rather  remarkable  that  the  patients  thus  afflicted  do  not  remember 
these  nocturnal  pains,  and  that  the  shrieks  of  different  patients  are  almost 
i&variably  of  the  same  note  and  duration. 

It  may  well  be  said  these  shrieks  are  as  characteristic  of  joint  disease 


Ill 


25 

•and  as  important  in  its  diagnosis,  as  the  peculiar  croup  tone  in  diphther- 
itic laryngitis,  and  the  cries  of  a  parturient  woman  in  the  last  period  of 
<3onfinement. 

As  already  remarked,  these  reflex  pains  occur  almost  exclusively  dur- 
ing the  night,  and  whilst  the  patient  is  dormant. 

In  a  few  exceptional  cases,  however,  I  have  met  the  symptom  under 
inverse  circumstances.  In  one  case  (Schindler)  the  pains  continued  for 
several  days  and  nights,  and  kept  the  affected  member  with  but  short 
intermissions,  in  a  constant  state  of  clonic  spasms,  and  until  the  flexors 
of  the  leg  had  been  divided. 

They  may  be  met  with,  irrespective  of  time,  when  contracted  muscles 
arc  put  upon  the  stretch. 

Whenever  the  reflex  pains  prevail,  the  patient  suffers  most  severely ; 
loses  flesh  and  appetite ;  becomes  anaemic,  and  prostrate,  and  the  disease 
of  the  joint  progresses  with  marked  rapidity. 

According  to  my  clinical  experience,  the  reflex  pains  chiefly  accom- 
pany bono  diseases,  and  in  these  they  arc  most  severe.  In  synovitis 
they  are  certainly  much  milder,  if  at  all  present. 

In  some  instances  the  reflex  pains  assume  the  character  of  genuine 
neuralgia,  and  follow  the  course  of  the  principal  nerves  ;  in  others  they 
discharge  their  violence  upon  certain  groups  of  muscles,  painfully  oscil- 
lating and  cramping  them,  leaving  them  in  a  state  of  cataleptic  tension. 

With  the  symptom  of  reflex  pain,  two  others  are  very  soon  ushered 
in: — 

1st,  Attenuation  of  the  a^ected  member. 

2nd.  Musculur  contraction. 

The  wasting  of  the  affected  extremity  is  as  common  a  symptom  of 
articular  diseases  as  it  is  conspicuous.  The  adipose  tissue  becomes 
rapidly  diminished,  and  finaiiy  extinct;  the  muscles  lose  their  bulk  and 
normal  contour,  the  bones  lose  in  circumference  and  length ;  the  ex- 
tremity assumes  a  cylindriform  shape ;  its  growth  is  arrested  ;  the  animal 
heat  is  below  the  standard  of  the  body,  and  in  cold  weather  the  extremity 
presents  that  mottled  appearance  which  is  so  common  in  paralysis. 

The  symptom  of  attenuation  is  co-ordinate  with  that  of  muscular 
contraction,  and  never  observed  without  the  latter. 

Among  the  many  hypotheses  advanced  in  explanation  of  this  symptom, 
that  of  Barwcll  is  about  the  most  superficial,  ascribing  it  to  the  per- 
manent compression  of  the  capillaries  within  the  muscular  structures. 
At  best  this  theory  would  apply  to  the  waste  of  muscles,  but  leaves  the 
^ther  structures  of  the  extremity  out  of  account. 

Without  entering  into  a  digest  of  the  various  opinions,  I  shall  content 


i  :! 


Ill 


26 


myself  with  offering  my  own.  It  requires,  indeed,  no  great  pathological 
acumen  or  diagnostic  sagacity  to  reduce  that  symptom  to  its  proper 
source.  It  consists  not  only  in  the  diminution  of  substance,  but  the 
arrest  of  growth  is  so  prominent,  that  impeded  innervation  and  impeded 
nutrition  must  be  charged  with  the  mischief,  for  which  pathology  furnishes 
ample  analogy. 

In  club-foot,  for  instance,  the  very  same  conditions  prevail,  the  same 
attenuation — the  same  arrest  of  growth  and  development — the  same 
reduction  of  temperature,  co-existing  with  muscular  contraction  and  mal- 
position. 

The  muscular  shortening  in  joint  diseases  is  well  known  to  careful 
observers,  but  its  pathological  character  has  as  yet  not  been  fully  appre- 
ciated by  the  profession.  la  carefully  analysing  the  facts  in  the 
premises,  I  shall  encounter  no  difficulty  in  establishing  views  fully  con 
sistent  with  the  nature  of  the  symptom  in  question. 

1st.  I  have  already  adverted  to  the  influence  of  the  reflex  pain  upon 
certain  muscles  appertaining  to  the  afibcted  articulation,  setting  them 
into  a  most  agonising  quiver.  This  symptom  is,  indeed,  so  con  mon, 
that  its  peculiarities  may  be  ascertained  beyond  a  shadow  of  doubt. 

2nd.  When  these  muscular  spasms  subside,  they  leave  its  structure  in 
a  state  of  rigor,  or  stationary  retraction  and  tenderness,  which,  however, 
gradually  disappear,  if  no  new  spasms  set  in. 

3rd.  Every  attempt  at  elongating  the  so  retracted  muscle,  by  gradual 
extension,  is  very  painful,  and  not  rarely  it  is  resisted  by  returning 
spasms. 

4th.  Faradayism  renders  the  state  of  so  retracted  muscles  still  more 
tender,  and  not  seldom  gives  rise  to  greater  and  painful  shortenings  of 
the  muscular  belly. 

5th.  During  anaesthesia  the  muscular  retraction  relaxes  and  allows 
full  extension,  which,  in  some  instances,  may  be  successfully  perpetuated 
by  appropriate  appliances.  In  others,  the  retraction  re-appears  with  the 
cessation  of  the  anaesthetic  effect ;  the  muscle  remains  tender  and  jerking. 
If,  under  these  circumstances,  the  extension  be  persist-ed  in,  the  articular 
disease  becomes  au'crravated. 

6th.  Persistent  retraction  terminates  in  structural  changes  of  the 
muscle,  and  destroys  its  expansibility,  both  physiologically  and  experi- 
mentally. Faradayism  produces  scarcely  any  excitation  whatever,  and 
chloroform  anasthaesia  exercises  no  marked  influence  upon  its  tension. 
Thus  the  muscle,  having  attained  its  maximum  of  contraction,  and  that 
contraction  being  rendered  permanent  by  organic  changes  of  its  structure^ 
the  term  contracture  has  been  fitly  applied  to  that  condition. 


27 


Dr.  Benedict,  of  Vienna,  rrnintains  that  a  constant  galvanic  current 
possesses  the  power  not  only  to  reduce  the  contraction,  but  to  establish 
the  physiological  expansibility  of  muscles  so  affected.  I  have,  however, 
not  seen  a  single  case  at  his  clinic  in  the  general  hospital  of  that  city 
that  could  be  accepted  in  proof  of  his  views. 

Nor  (lan  the  successful  hrisement  foixe,  without  myotomy,  pass  as 
evidence,  since  the  violence  generally  employed  is  quite  sufficient  to  tear 
asunder  all  resisting  structures — myolemma  or  muscular  fibres — thus 
virtually  accomplishing  the  same  results  as  would  be  produced  by  dividing 
the  contracted  muscle. 

7th.  The  subcutaneous  division  of  the  contracted  muscle  overcomes 
both  resistance,  spasm,  and  attending  pains. 

8th.  The  division  of  contracted  muscles  exercises  the  most  beneficial 
influence  upon  the  affected  extremity,  in  promoting  its  nutrition,  growth, 
and  development.  Even  the  muscles  themselves  become  more  bulky  and 
susceptible  to  the  action  of  Faradayism. 

The  contractures  of  muscles,  force  of  course,  the  affected  extremity  into 
a  position  corresponding  to  their  respective  traction,  and  they  become 
therefore  the  source  of  malpositions. 

In  all  joint  diseases  some  muscles,  or  group  of  muscles  are  invariably 
contracted  to  the  exclusion  of  others.  Thus  for  instance,  in  morbus 
coxarius,  we  find  the  adductor  muscles  of  the  thigh,  and  some  of  the  flexor 
muscles  materially  shortened.  Among  the  adductors,  the  pectineus ;  and 
among  the  flexors,  the  tensor  vaginae  feraoris,  are  the  most  implicated . 
In  consequence  of  these  contractions,  the  affected  extremity  is  unduly 
flexed,  and  adducted  and  rendered  apparently  shorter  than  its  fellow,  the 
disparity  being  increased  by  the  elevation  and  rotation  of  the  correspond- 
ing side  of  the  pelvis.  In  affections  of  the  knee  joint  the  Viceps  muscle 
is  commonly  the  only  one  contracted,  and  but  exceptionally  the  remain- 
ing flexors  become  involved.  Hence  the  affected  member  is  more  or  less 
flexed  at  the  knee  joint,  and  in  the  higher  degree  of  flexion,  the  leg  is 
rotated  on  its  longitudinal  axis,  and  the  toes  everted.  This  position  im- 
plies an  anatomical  derangement;of  the  respective  parts  of  the  joint,  the 
external  condyle  of  the  tibia  receding,  and  the  internal,  protruding  in  front 
of  the  joint.  In  affections  of  the  tibio-tarsal  and  tarsal  articulations,  the 
peroneii  muscles  are  retracted,  and  ther'jby  the  foot  rotated  so  as  to  give 
it  the  position  of  talipes  valgus.  In  affections  of  the  wrist  joint  we  meet 
with  contractions  of  the  flexor  radialis  and  ulnaris,  with  abnormal  flexion 
of  the  hand ;  sometimes  but  one  of  those  muscles  is  shortened,  and  the 
hand  has  a  corresponding  leaning  in  its  direction.  In  affections  of  the 
elbow  joint  the  biceps  muscle  and  the  pronator  teres  are  involved  keeping 


fj 


f' 


iii 


.„ 


28 

the  forearm  in  a  state  of  pronation  and  flextion.  In  affections  of  the  shoul- 
der joint  we  notice  the  contraction  of  the  pectoralis  major,  with  adduc- 
tion of  the  arm  to  the  body,  &c. 

It  is  self  evident  that  the  contraction  of  certain  muscles  in  certain 
joint  diseases  is  by  no  means  accidental  but  governed  by  the  supply  of  co- 
ordinate nervous  fibres.  Schwun  by  his  very  careful  and  minute  dissec- 
tions, has  fully  established  the  fact,  that  such  a  co-ordination  of  nerves 
exists,  supplying  joints  and  muscles.  And  Hilton,  another  reliable  ana- 
tomist, has  affirmed  that  anatomical  arrangenient.  But  even  without  these 
anatomical  facts,  clinical  observation  would  be  justified  in  such  an  infer- 
ence. ' 

In  most  joint  diseases  there  is  more  or  less  immobility.  To  a  certain 
extent  the  immobility  is  of  a  voluntary  character  employed  by  the  patient 
to  obviate  the  paincausedby  the  exercise  of  the  affected  joint.  Frequently, 
and  in  advanced  cases,  the  immobility  may  arise  from  hydraulic  pressure 
upon  the  articulating  surfaces,  by  effusion  into  the  joint,  as  may  be  seen 
in  the  second  stage  of  hip  disease,  and  in  some  affections  of  the  knee 
joint  with  unyielding  and  thickened  walls. 

The  deposits  of  osseous  inaterial  around  the  joint,  and  osteophytes, 
will  produce  the  same  effect.  Muscular  contractions  are  a  material  im- 
pediment to  the  mobility  of  affected  joints. 

I  have  already  referred  to  malposition  of  the  respective  affected  articu- 
lations, as  one  of  the  general  symptoms  attending  articular  diseases,  and 
adduced  its  most  prominent  cause.  There  are  however  other  causes  which 
occasionally  bring  about  that  result.  One  of  them  is  the  gradual  disin- 
tegration of  the  epiphysis.  Next  the  separation  of  the  epiphysis  and  its 
dislodgement  from  the  shaft.  Another,  the  fracture  of  the  epiphysis 
eventuating  in  joint  disease.  The  last  though  not  least  is  effusion  within 
the  articular  cavity.  The  experimental  injections  into  joints  made  by 
Weber  and  Bonnet  demonstrate  that  liquids  forcibly  thrown  into  the 
articular  cavities  through  an  aperture  of  a  stationary  bone  will  force  the 
movable  part  of  the  joint  into  certain  positions  denoting  the  greatest 
capacity  of  the  articulation. 

Similar  changes  in  the  position  of  joints  are  produced  in  the  living 
body  by  effusions.*  But  in  order  to  accomplish  this  the  walls  of  the  articu- 
lation require  to  have  been  rendered  unyielding  to  the  process  of  inflam- 
mation, in  which  case  the  effusion  acts  like  a  wedge  driven  between  the 
.articular  surfaces.     As  long  as  the  walls  remain  flaccid,  or  retain   their 


•  Collateral  with  more  or  less  perfect  immobility. 


29 


healthy  elasticity ;  an  immense  quantity  may  be  accumulated  in  the  joint 
without  any  effect  upon  its  position,  as  is  the  case  in  ordinary  hydrathro- 
fiis. 

Last,  I  have  to  mention  fever,  as  one  of  the  common  symptoms  of  joint 
diseases.  This  symptom  is  merely  of  temporary  duration,  and  accompa- 
nies only  the  higher  grades  of  these  affections,  their  inflammatory  periods, 
or  at  times  when  a  mighty  local  irritation  exists,  be  this  through  foreign 
bodies,  sacculated  pus,  or  the  like.  It  generally  subsides  with  the  removal 
or  alleviation  ot  che  local  disturbance.  In  all  these  instances  the  fever  is 
strictly  symptomatic.  Rheumatic  affections  of  joints  are  however,  usher- 
ed in  with  marked  febrile  excitement,  which  seems  to  form  an  essential 
part  of  the  morbid  process. 

Profuse  and  continuous  suppuration  of  joints  is  mostly  attended  by 
hectic  fever,  which  presents  the  usual  characteristics.  But  rarely  do  we 
meet  with  pyaemia,  caused  by  affection  of  the  joints.  I  do  not  think  that 
I  have  seen  more  than  a  dozen  cases,  in  all  in  my  practice.  The  latest 
refers  to  a  little  girl,  eleven  years  old,  of  very  delicate  constitution.  From 
causes  unknown,  she  was  attacked  almost  simultaneously  with  an  affec- 
tion of  the  left  tibio-tarsal  joint,  and  periostitis  of  the  corresponding 
tibia,  both  disorders  eventuating  rapidly  in  suppuration.  A  few  weeks  after 
the  first  attack,  a  large  abscess  had  formed  during  one  night  at  the  left  hip, 
another  soon  afterwards  made  its  appearance  below  the  right  clavicle,  soon 
to  be  followed  by  a  third  in  the  right  hip. 

It  is  yet  doubtful  in  my  mind  whether  this  case  does  not  come  under 
the  head  of  spontaneous  pyaemia,  a  form  which  is  seriously  doubted  by 
some  authors,  or  whether  pyasmia  resulted  from  the  original  affection. 

The  division  of  joint  diseases  into  acute  and  chronic  forms,  is  rather 
inappropriate,  because  artificial.  It  is  apt  to  confound  the  character  of 
the  affection,  and  has  no  practical  value  in  any  respect.  Whether  the 
duration  of  the  malady,  or  the  violence  of  the  symptoms  is  the  principle 
of  division  we  shall  find  neither  to  u?  tenable. 

Almost  every  joint  disease  assumes  a  protracted  course,  and  is  thus 
essentially  chronic.  But  few  exceptions  can  be  adduced  to  this  rule. 
Rheumatic  synovitis  may  be  of  short  duration,  and  characterized  by 
violent  symptoms,  but  joints  thus  affected  will  require  months  to  recover 
their  normal  status.  On  the  other  hand,  we  observe  periods  of  acuity, , 
in  the  most  chronic  and  protracted  joint  diseases,  which  may  challenge 
the  most  acute  forms  known. 

I  suggest,  therefore  to  drop  a  clinical  dogmatism,  worthless  to  the 
experienced  surgeon,  and  confusing  to  the  novice. 

The  symptoms  by  which  synovitis  is  characterized,  materially  vary, 


m 

I 


(1 


i'l 

I 

8;!  *  '■ 


30 


l)oth,  in  duration  and  intensity.  "We  need  scarcely  adduce  the  general 
symptoms  of  this  disease,  having  already  alluded  to  them  on  a  prior 
occasion. 

The  chief,  and  pathognomonic  phenomenon,  is  effusion  within  the  arti- 
cular cavity,  and  rapid  change  in  the  contours  of  the  joint.  From  the 
physiological  character  of  the  structure,  effusion,  should,  a  priori,  be 
expected,  as  clinical  observation  substantiates  it. 

To  speak  of  a  dry  joint  in  these  affections  is  nn  absurdity.  The  most 
insignificant  irritation  of  the  synovial  lining,  is  attended  with  copious 
secretion  of  a  fluid,  with  the  peculiarities  of  synovia.  The  higher  grades 
may  not  exhibit  the  same  quantity  of  morbid  secretion,  but  enough  to 
give  definite  fluctuation.  The  liquid  is  of  a  more  plastic  nature,  con- 
tains blood  corpuscles,  flakes  of  fibrin,  fat  globules  and  epithelium  and 
becomes  early  contaminated  by  the  organized  elements  of  pus.  To  a 
certain  extent  the  composition  of  the  synovial  fluid  may  still  be 
recognized  by  the  abundance  of  alkalies  and  the  soapy  feel. 

In  the  highest  grade  of  synovitis,  the  synovial  lining,  is  as  you  are 
aware,  converted  into  a  pyogenic  membrane,  and  presents  the  structure 
of  granulations,  as  stated  in  the  preceding  section  of  our  discourse. 
Under  all  these  conditions,  there  is  more  or  less  morbid  effusion. 

The  dryness  of  articulations  cannot  be  denied,  but  it  is  noticed  in 
conditions  of  a  different  character,  and  independent  of  inflammatory 
affections  of  the  synovial  lining.  Thus,  for  instance,  it  complicates  pro- 
gressive deformative  arthritis,  which  originates  in  the  articular  faces  of 
the  bones  and  though  the  synovial  membrane  may  gradually  be  com- 
promised, it  is  affected  in  such  a  manner  as  to  destroy  its  character  as  a 
secreting  structure. 

In  white  swelling,  the  synovial  membrane  sometimes  piesents  the 
peculiarity  of  dryness,  but  from  anatomical  changes  of  a  pulpy  charac- 
ter, not  the  result  of  direct  inflammation. 

In  pure  synovitis  we  never  observe  consecutive  intumescence,  infiltra- 
tion, or  hardening  of  the  surrounding  tissues,  and  never  to  such  an 
extent  as  we  find  it  in  diseases  of  the  periosteum,  and  the  osseous  strnc- 
ture,  unless  indeed  the  latter  have  become  involved. 

In  the  more  active  forms,  there  is  intense  pain  within  the  whole  joint, 
with  consecutive  febrile  excitement ;  but  reflex  pains  are  moderate,  and 
the  spastic  oscillations  never  very  intense  In  the  lower  grades  of  syno- 
vitis (Hydrarthrosis),  these  symptoms  are  entirely  wanting,  and  the 
patient  suffers  scarcely  any  other  inconvenience,  than  the  effusion  within 
the  joint  would  naturally  occasion. 

The  affections  of  the  periosteum  and  of  the  epiphyses,  are  attended  by 


31 


la 

In 


a  widely  diiForent  group  of  symptoms.  Tho  beginning  of  these  diseases 
is  very  insidious,  and  their  development  so  slow  as  to  require  months  to 
a(psumc  u  noticeable  form.  But  little  pain  attends  the  initiatory  period. 
The  whole  trouble  marks  itself  os  weakness  of  the  limb,  dryness  and 
stiffness  of  the  joint,  with  inability  to  use  the  extremity  in  the  morn- 
ing. For  a  time  the  contours  of  the  joint  suffer  no  change ;  and  if  there 
be  any  fulness  at  all,  it  is  more  generally  diffused,  and  extends  beyond  the 
limits  of  the  articulation.  There  is  no  discoloration  of  the  integuments, 
though  there  is  frequently  that  u'«a;^  whiteness,  the  result  of  oedema; 
whence  the  term  "  white  swelling."  The  latter  is  often  the  first  symp- 
tom which  attracts  attention.  Though  the  patient  may  have  the  sensa- 
tion of  heat  in  the  affected  parts,  it  is  not  ohjective  cither  to  the  hand  or 
thermometer.  The  patient  may  gradually  experience  son.-^  difficulty  in 
using  the  articulation  to  the  fullest  extent,  feel  induced  to  spare  the 
extremity  in  locomotion,  and  thus  favor  certain  positions  as  a  source  of 
greater  comfort ;  malposition  is  superadded  only  at  a  later  period. 

The  advance  of  the  disease  is  marked  by  progressive  swelling  of  the 
periarticular  structures :  the  contours  of  the  joint  disappear,  not  from 
effusion  within  the  articular  cavity,  but  from  infiltration  of  the  surround- 
ings and  therefore  no  fluctuation  can  be  discerned. 

Contemporaneous  with  the  enlargement  of  the  articulation,  the 
original  feeling  of  soreness,  increases  to  aching  pain,  being  augmented 
by  pressure  and  locomotion  ;  the  rest  becomes  disturbed  by  reflex  pains, 
and  the  limb  forced  into  a  position  over  which  the  patient  loses  all  con- 
trol. Every  attempt  to  alter  the  same  is  attended  with  aggravated 
iSuffering. 

When  the  swelling  and  firmness  of  the  soft  parts  still  more  increr.se, 
then  the  pain  assumes  a  torturing  character.  The  limb  attenuates  and 
becomes  cooler,  whilst  the  swelling  shows  but  a  moderate  addition  of 
\  jmperature. 

In  viewing  the  affected  extremity,  the  contrast  between  the  waste  of 
the  limb,  and  the  general  enlargement  of  the  articulation,  with  its  nume- 
rous distended  veins,  is  strongly  marked,  and  it  is  this  form  of  articular 
disease,  which  in  times  past  was  designated  as  fungus  articulorum, 
tumor  alius,  and  ivhite  swelling.  It  was  thought  to  be  of  malignant 
growth,  and  amputation  its  only  remedy. 

Thanks  to  the  progress  of  pathological  anatomy  and  tho  material  aid 
of  the  microscope,  this  error  of  our  ancestors  has  been  effectually  dis- 
pelled. 

Now-a-days,  white  swelling  has  been  recognised  as  an  affection  of  the 
articular  ends  of  bones,  and  their  respective  periosteum  ;  with  subsequeni 


M  I 

m 


■t :     I 


p^r 


32 


)'. 


periarticular  infiltrations  of  seroplastic  material,  with  its  attending  orga- 
nization into  fibroplastic  cells,  fibrous  structure,  fat,  &c.  And  surgery 
oflFers  tha  means  of  relief  as  long  as  the  pathological  changes  axe  suscep- 
tible Of  reduction. 

The  knee  joint  is  most  frequently  visited  with  this  disease,  and  it  is 
there  one  can  best  study  its  different  phases. 

On  a  former  occasion  I  have  assigned  the  reasons  why  this  malady 
attacks  the  knee  joint  more  frequently  than  any  other,  and  likewise  why 
the  disease  is  more  frequently  observed  in  childhood  than  in  adult  age: 
and  therefore  need  not  recur  to  that  subject. 

I  shall  now  confine  my  remarks  to  the  discussion  of  some  features  that 
characterize  the  process  under  consideration. 

One  of  these  points  is  the  extraordinary  slow  advance  of  the  disease. 
Some  authors  think  that  a  low  grade  of  nutrition  of  the  structures  pri- 
marily involved,  offers  an  acceptable  explanation.  On  close  reflection 
we  shall  find  this  view  inadmissable,  and  contradictory  to  analogy.  Nu. 
trition  in  childhood  is  more  exuberant  than  at  any  later  period.  In  the 
former,  maintenance  is  not  the  only  object  of  the  nutritive  process ;  it  is 
enhanced  by  growth  and  developement,  demanding  more  ready  supply, 
and  meeting  with  the  most  elastic  condition  of  the  vascular  carriers  of 
that  supply.  In  these  advantages  the  infantile  skeleton  participates  ta 
a  higher  degree  than  the  other  systems  of  the  organism. 

Hence  from  a  physiological  point  of  view,  we  have  to  reject  the  ad- 
vanced theory. 

In  questioning  analogy,  we  notice  facts  which  demonstrate  beyond  a 
shadow  of  doubt,  the  prolific  character  of  nutrition  in  the  osseous  system 
of  children.  Fractures  consolidate  more  rapidly  with  them  than  with 
adults ;  artificial  joints  are  scarcely  ever  observed  during  the  period  of 
evolution  ;  if  periostitis  has  laid  bare  the  bone  of  a  child,  exfoliation  rapid- 
ly ensues,  and  sequestra  form  much  more  quickly  than  at  a  later  period. 
Tliesc  facts  coincide  with  the  exporiments  of  Flourent  and  Wagner,  and 
dispose  effectually  of  the  before  mentioned  hypothesis. 

In  all  those  cases  of  white  swelling,  that  I  have  had  the  opportunity  of 
anatomically  investigating,  and  they  have  been  numerous,  I  have  observ- 
ed that  there  is  always,  in  one  or  the  other  condyle,  an  insular  disinte- 
gration of  the  cancellated  structure,  in  which  sometimes  a  small  seques- 
trum is  imbedded.  Under  the  microscope  scarcely  any  trace  of  the  van- 
quished structure  can  be  discerned.  The  chief  clement  is  fat.  But  in 
the  neighbourhood  of  this  pathological  focus,  hyperacmia,  traces  of  fun- 
goid granulations,  and  osteoporosis  are  noticed.  This  condition  explains 
satisfactorily,  the  proximate  cause  of  the  pathological  changes  inconsis- 


i 


tent  with  the  active  process  of  ostitis.  In  some  rare  instances,  however, 
the  healthy  portion  of  the  bone  surrounds  tlic  disintegrated  isle  with  a 
sclerotic  capsule,  by  which  the  afFccted  portion  becomes,  as  it  were,  isola- 
ted and  rendered  innocuous,  in  a  similar  manner  as  foreign  bodies  en- 
capsule.  This  pathological  condition  may  not  cover  all  cases  which 
pass  under  the  name  of  tumor  albus,  but  certainly  this  is  the  most  preva- 
lent. 

There  is  a  specimen  in  my  collection,  of  the  lower  third  of  a  femur 
of  a  young  girl  not  exceeding  fifteen  years  of  age.  She  was  admitted  to 
the  Brooklyn  Medical  and  Surgical  Institute,  with  all  the  symptoms  of 
white  swelling,  comprising  the  articulation  and  peri-articular  structures  ; 
the  swelling  however  likewise  involved  a  portion  of  the  femur.  The  local 
disturbances  were  as  intense  as  were  the  nocturnal  pains,  and  the  spasms 
of  the  flexor  muscles.     The  knee  was  of  course  drawn  to  a  right  angle. 

From  the  history  of  the  case,  and  the  clinical  character  of  the  disease, 
circumscribed  osteomi/dlfis,  with  its  termination  in  abscess  was  diagnosed, 
and  in  view  of  her  reduced  constitution,  and  the  copious  discharge 
of  matter  from  the  neiglibourhood  of  'ic  joint,  amputation  was  deemed 
expedient. 

The  condition  of  the  specimen  fully  confirmed  the  diagnosis.  There 
is  a  large  pyogenic  cavity  at  the  lower  end  of  the  femur,  which  opens  at 
the  posterior  aspect  of  the  bone,  by  an  irregular  aperture  not  less  than  an 
inch  and  a  half  in  diameter  ;  in  thecircuniforeiice  of  which,  the  periosteum 
is  raised  up,  and  its  internal  surface  covered  with  new  bone.  The  epiphysis 
is  somewhat  loosened  from  its  attachment,  and  in  time  would  have  become 
separated. 

The  original  focus  of  the  dicsease  had  been  obviously  limited  to  the 
cancellated  structure,  and  rather  remote  from  the  joint,  but  its  consecu- 
tive effects  had  extended  over  the  joint,  and  involved  its  soft  surround- 
ings. There  may  be  still  other  exceptions  from  the  anatomical  prototype, 
but  their  numerical  proportions  scarcely  affect  the  statistics. 

The  adherents  of  the  tubercular  theory,  may  rejoice  at  this  patliological 
admission  of  mine,  of  those  insular  and  circumscribed  pathological  foci, 
which  they  may  claini  as  bona  fide  evidence  of  tubercular  deposit. 

I  hold  however,  that  pathological  detritus,  limited  to  an  isolated  place, 
cannot  in  the  eyes  of  competent  judges,  pass  as  tubercle. 

If  the  disease  is  permitted  to  spread,  it  eventuates  in  perforation 
of  the  articular  cavity  ;  the  formation  of  external  abscesses  and  fistulous 
tracts,  and  the  more  obstacles  the  discharge  has,  the  more  periosteum  will 
bo  destroyed,  and  the  bone  corroded  on  its  surface. 

The  protracted  development  of  these  phases  extends  over  many  months. 


ii! 


.;i  \'\ 


A 


1 


Ilv-J 


34 


and  often  additional  injuries  are  required  to  accomplLsh  so  extensive 
disintegration. 

A  lull  of  all  symptoms,  is  often  observed  in  the  like  cases,  to  be  follow- 
ed by  new  exacerbations.  A  goodly  number  recover  spontaneously,  or 
by  appropriate  treatment.  These  recoveries  happen  not  rarely  at  the  period 
of  puberty,  at  which  time  the  mode  of  nutrition  of  the  epiphyses  becomes 
perfected. 

In  analysing  tTie  gradual  development  of  this  disease,  its  preceding 
cause,  (traumatic  injuries)  ;  the  comparative  moderate  c  /ccts  upon  the 
integrity  of  the  adjacent  osseous  structure  ;  we  find  a  more  passive  path- 
ological condition,  a  direct  necrobiosis  of  the  affected  structure,  more  from 
want  of  proper  maintenance,  than  from  active  and  progressive  disease. 
When  active  symptoms  subsequently  set  in,  they  are  the  eflforts  of  the  vi& 
medicatrix  naturcv  to  eliminate  the  detritus  foreign  to  the  integrity  of  the 
bone.  Frequently  the  detritus  becomes  absorbed,  or  pe  vaded  with  cal- 
careous elements,  and  thus  recovery  is  attained. 

This  gradual  change  of  the  osseous  structure  and  annihilation  of  its 
nervous  and  vascular  endowments,  though  limited  in  extent,  renders  it 
intelligible  why  so  little  pain  is  experienced  by  the  patient,  during  the 
first  disintegrating  period  of  the  disease.  The  intense  pain  that  is  at  a 
later  period  superinduced,  is  evidently  connected  with  toe  peripheral  and 
active  process  of  osteitis  arising  in  the  circumference  of  the  focus.  The 
original  disease  has  nothing  to  do  with  it. 

The  appearance  oJ  nocturnal  pain  constitutes  a  serious  complication 
and  indicates  the  commencement  of  suppuration. 

The  contraction  of  the  biceps  muscle  is  quite  common,  and  the  result 
of  reflected  spasm.  The  leg  is  thus  held  in  an  angular  position  to  the 
thigh,  and  most  usually  rotated  on  its  longitudinal  axis,  with  eversion 
of  the  toes.  T^liis  position  goon  pari  ^jass?*,  with  an  anatomical  derange- 
ment of  the  joint  itself  The  patella  rides  upon  the  external  condyle  of 
the  femur,  and  is  generally  adherent ;  the  internal  condyle  of  the  tibia 
projects  in  front,  whilst  the  external  one  recedes. 

The  contraction  of  the  biceps  is  exclusively  accountable  for  this  mal- 
position, for  at  a  certain  angle  it  acts  as  a  rotator,  when  not  counteracted 
by  the  simultaneous  contraction  of  the  internal  hamstrings. 

I  have  but  lately  exhibited  to  the  New  York  Pathological  Society  a 
specimen  of  this  kind,  and  the  action  of  the  biceps  is  so  undeniably  de- 
monstrated, that  there  is  no  more  room  for  further  speculation  to  ac- 
count for  the  symptoms. 

For  a  long  time  the  mobility  of  the  affected  joint  remains,  if  not  im- 
peded by  the  contraction,  but  when  synovitis  is  superinduced  to  the 


35 


original  affection,  the  joint  may  become  obliterated  by  fibrous  adhesions 
between  the  articular  faces,  which  may  still  more  impede  the  mobility, 
but  rarefy  are  there  osteophytes  passing  from  one  bono  to  the  other, 
depriving  the  joint  of  all  vestige  of  motion.  True  bony  anchylosis  is  of 
very  rare  occurrence,  and  much  more  the  consequence  of  penetrating 
wounds  of  the  joint,  and  high  graded  synovitis,  than  of  this  form  of 
disease. 

Whether  the  disease  originates  in  the  synovial  membrane,  in  the 
crucial  ligaments,  in  the  periosteum,  or  the  epiphysis  of  the  joint,  the 
symptoms  apertaining  to  each  of  them  respectively,  will  be  so  blended  in 
their  advanced  course,  as  to  render  diagnostic  discrimination  almost  im- 
possible, leaving  the  previous  history  as  the  only  guide. 

The  pathological  conditions  of  joint  disease^,  vary  but  little,  when 
suppuration,  burrowing  of  pus,  has  been  going  on,  and  the  bones  have 
been  disintegrated  for  any  length  of  time  ;  the  symptoms  attending  those 
conditions  are  almost  uniform  in  all  such  cases.  The  competent  and 
experienced  surgeon  may  yet  recognize  the  patho -genesis  of  the  original 
disease,  but  novices  rarely  realize  differences  so  indistinct  and  sub- 
tle. Thus,  in  caries  of  the  joint  emanating  from  synovitis,  the  articular 
surfaces  arc  more  generally  denuded  of  their  respective  cartilaginous 
coverings,  but  the  osteo-porosis  does  not  much  exceed  the  surface ;  the 
crucial  ligaments  are  but  partially  destroyed ;  the  semilunar  cartilages 
partly  disintegrated,  discolored,  and  mostly  detached.  On  moving  the 
articulation,  crepitus  is  discernible.  If,  however,  the  bone  has  been  the 
starting  point  of  the  disease,  the  caries  of  the  articular  surface  is  gener- 
ally restricted  to  the  originally  affected  locality ;  and  the  cartilage  is 
there  and  thereabout  disintegrated.  The  crucial  ligaments  are  mostly 
destroyed  in  toto,  and  crepitus  is  less  distinct. 

The  clinical  character  of  hip  disease  will  now  demand  attention,  on 
account  of  some  peculiarities  in  its  manifestations.  Morbus  coxarius  is 
about  as  good  a  term  as  could  be  chosen  and  certainly  more  appropriate 
than  "  coxalgia  "  which  applies  solely  to  the  pain  of  the  affection. 

The  Jirst  stage  of  tins  lesion  materially  conforms  with  the  same  stage 
of  the  affections  of  other  joints.  The  only  symptom  requiring  special 
mention,  is  limping.  It  is  most  noticeable  in  the  morning,  less  during 
the  day,  and  least  towards  evening ;  most  conspicuous  after  great  exer- 
tion, and  sometimes  absent  after  a  day  of  complete  rest.  The  duration 
of  this  period  is  variable ;  repeated  accidents  and  the  continuous  use  of 
the  affected  extremity  may  sliorten,  and  constant  rest  prolong  it. 

The  so  characteristic  pain  at  the  knee,  may  already  muko  its  appear- 
ance at  this  stage,  but  if  so,  there  will  be  likewise  indications  ol'  retracted 


:l! 


i  ! 


hi 


wm^mm 


ill 


■I 


.  I 


lii 


muscles,  with  which  this  symptom  appears  conjointly.  This  pain  has 
often  confounded  the  diagnosis  of  the  less  experienced,  without  any 
need;  for  you  may  press  and  squeeze  the  knee  joint  as  you  please,  witli- 
out  the  slightest  increase  of  that  pain,  whereas  the  pressure  upon,  and 
movement  of  the  hip  joint  will  aggravate  it.  The  progress  of  the  malady 
may,  at  this  ju'icture  be  arrested,  and  the  patient  relieved  from  further 
trouble. 

The  second  Stage  is  characterized  by  elongation,  abduction,  eversion 
and  slight  flexion  of  the  aft'ected  limb  at  the  hip,  with  lowering  of  the 
pelvis,  flattening  of  the  gluteal  region,  sinking  of  the  gluteal  fold,  and  an 
inclination  of  the  internatal  fissure,  at,  and  towards  the  aft'ected  side. 
The  mobility  of  the  joint  may  either  be  impeded,  or  entirely  suspended. 
Adduction  is  generally  impossible. 

For  the  purpose  of  locomotion,  the  patient  brings  the  lumbar  portion 
of  the  spine  and  the  other  hip  joint  into  play  ;  thereby  easily  deceiving 
the  inexperienced  observer.  In  the  erect  posture  the  spine  exhibits  a 
single  curve,  of  which  the  convexity  corresponds  with  the  seat  of  trouble. 
The  superior  spinous  process  of  the  ilium,  is  depressed  when  compared 
with  that  of  the  other  side,  and  the  healthy  member  is  adducted  in  pro- 
portion to  the  malposition  of  its  afflicted  fellow.  In  walking,  the  patient 
places  the  latter  forward  and  outward,  and  drags  the  other  limb  after  it 
in  a  rather  diagonal  direction.  All  these  symptoms  more  or  less  complete, 
can  be  ascertained  by  undressing  the  patient ;  dropping  a  plummet  line 
from  the  occipital  protuberance,  walking,  and  by  careful  examination  in 
the  horizontal  posture.  If  the  patient  sit^^  down  in  such  a  manner  as  to 
accommodate  the  aft'ected  member,  both  pelvis  and  spine  assume  normal  re- 
lations, thus  proving  that  the  elongation  of  the  limb  does  not  depend  on 
the  lateral  declivity  of  the  pelvis,  as  ^'Gross  asserts. 

The  chief  or  proximate  cause  of  the  entire  group  of  symptoms  rests 
with  the  immobility  of  the  joint  and  the  fixed  adducted  position  of  the 
extremity.     In  imitating  tliem  wc  produce  the  very  same  efi'ect. 

There  can  be  no  doubt  tliat  the  elongation  is  but  apparent,  and  not 
real,  as  the  late  professor  Rust  of  Berlin,  claims.  Nor  is  there  any  en- 
largement of  the  head  of  the  femur,  from  cither  tuberculosis  or  other 
causes,  to  which  he  ascribes  the  actual  elongation.  The  sole  source  of 
the  symptom  is  hydraulic  pressure  from  existing  intra-articular  effusions. 
I  was  led  to  this  view  from  the  analogous  position  of  the  femur  and  the 
immobility  of  the  joint  produced  by  experimental  injection.  Acting  on 
this  supposition,  1  have  succeeded  in  substantiating  the  correctness  of 

♦Uroas'  "  I'rucliciil  Ubscrvalious  "    I'liiladt'l^liia  1859, 


nn 


■*^1 


a7 


ts 
le 


jn- 


of 


of 


my  opinion,  by  paracenteses  of  the  articular  cavity.  The  removal  of  the 
intra-articular  fluid  was  followed  immediately  by  returning  mobility  and 
the  correction  of  the  malposition.  This  point  is  consequently  settled  by 
demonstrable  evidence. 

With  the  apparent  elongation  of  the  limb,  the  structural  pain  gradual- 
ly increaseSj  and  the  reflex  symptoms  rapidly  rise  to  an  intense  degree. 
The  nocturnal  pains,  in  this  period  are  more  violent  and  torturing  than 
at  any  later,  and  for  obvious  reasons.  Whilst  the  extremity  is  immova- 
bly fixed  by  hydraulic  pressure,  the  adductor  muscles  are  nightly  agita- 
ted by  reflected  spasms,  and  kept  on  the  stretch.  The  limb  becomes 
attenuated  and  exhibits  marked  disproportion  with  its  fellow,  the  con- 
stitution, rest,  appetite,  suffer  gravely,  and  reduce  the  patient  in  weight 
and  appearance.  The  eff'usion  may  still  be  of  a  plastic  and  organizable 
character ;  sero-purulent,  or  exclusively  pus :  may  be  free  from,  or  con- 
taminated with  structural  detritus,  benign  or  destructive.  Its  composi- 
tion will  naturally  determine  the  issue  of  the  case.  If  the  eff'usion  be 
mild,  plastic,  benign,  free  from  deleterious  admixture,  its  partial  absorption 
and  final  organization  into  fibrous  structure  may  take  place,  and  thus  ter- 
minate the  malady.  Or  its  quantity  may  lead  to  a  disruption  of  the  cap- 
sular ligament,  and  the  escape  of  the  intra-articular  effusion  into  the  sur- 
roundings of  the  joint,  and  there  become  organised  and  innocuous. 
Through  similar  changes  the  sero-purulent  effusion  may  pass  with  the 
same  result. 

But  if  the  articular  contents  are  of  a  destructive  character,  they  may, 
by  macerating  and  corroding  the  acetabulum  pass  into  the  pelvic  cavity 
through  the  cotyloid  notch,  or  through  the  capsular  ligament,  and  will 
invariably  give  rise  to  the  formation  of  abscess,  corresponding  in  lo  cality 
with  the  place  of  perforation. 

Ill  the  moment  the  perforation  is  effected  a  new  scries  of  symptoms 
appears,  and  with  which  the  third  stage  of  the  disease  is  ushered  in. 

The  third  stage  is  distinguished  by  diametrically  opposite  symptoms. 
The  contrast  of  the  two  stages  can  best  be  realized  by  placing  them  in 
juxtaposition. 


Second  stage. 

Affected  limb. 

Apparently  elongated. 

Abducted. 

Flexed  at  hip  and  knee. 

Toes  everted. 

Foot  fully  on  the  ground 

Healthy  limb  adducted 

Pelvis  lowered. 


Third  stage. 
Allt'cted  limb. 
Apparently  sshortened. 
Adducted. 
Flexed  at  hip. 
Toes  inverted. 
Uall  of  toes  only. 
Abducted. 
Tilted  up. 


i 


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Iff ' 


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ill; 

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38 

Pelvis  projects  forward. 

Pelvis  angle  of  inclination  acute. 

Nates  flattened. 

Gluteal  fold  lowered. 

Interaatal  fissure  inclined  to  affected 

side. 
Spine  curved  on  the  affected  side 

Nocturnal  pain  very  intense. 


Backward. 
Almost  rectangular. 
Full  and  convex. 
Elevated. 

Inclined  towards  the  op- 
posite side. 
Curved  towards  the  other 

side. 
Greatly  diminished. 


It  will  be  seen  that  the  third  stage  is  characterised  by  unmistakeablc 
clinical  manifestations,  and  by  so  peculiar  a  gait  of  the  patient,  as  to  be 
recognised  at  a  distance. 

The  shortening,  adduction,  and  inversion  of  the  limb,  conjointly  with 
the  rotundity  of  the  gluteal  space,  strongly  convey  the  impression  of 
posterior  superior  dislocation  of  the  femur.  This  similarity  of  the  two 
mav  have  led  Rust  to  presume  their  identity,  and  ascribe  to  the  action 
of  the  contracted  muscles  the  cause  of  spontaneous  dislocation.  The 
morbid  enlargement  of  the  caput  femoris,  said  to  exist  (at  the  second 
stage)  lent  a  plausible  argument  to  this  hypothesis.  What  was  more 
simple  and  transparent,  than  that  the  head  of  the  femur  partially  expel- 
led frorr?,  the  acetabulum  by  its  disproportionate  size,  should  leave  it 
entirely,  and  follow  the  undue  traction  of  the  muscles.  This  hypothesis 
of  the  renowned  German  surgeon  prevailed  among  the  profession  ;  spon- 
taneous dislocation  was  henceforth  a  settled  fact,  against  which  but 
heterodoxy  could  raise  its  voice.  Buehring,  of  Berlin,  if  I  do  not 
mistake,  was  the  first  who  took  issue  with  Rust's  theory,  and  attempted 
to  reduce  the  acknowledged  similarity  of  symptoms  to  causes  widely 
different  from  those  propounded.  In  this  effort,  he  derived  material 
assistance  from  the  advancement  of  pathological  anatomy.  The  ques- 
tion once  opened  has  received  a  rational  solution.  At  this  present  mo- 
ment there  are  few  well  informed  surgeons  who  recognize  spontaneous 
dislocation.  Nelaton  has  informed  us  of  a  good  method  to  decide  the 
relative  position  of  the  femur  to  the  pcetubulum.  In  drawing  a  line 
from  the  anterior  superior  spinous  process  of  the  ilium,  to  the  tuberosity 
of  the  ischium,  it  passes  on  its  way,  from  one  point  to  the  other,  the 
apex  of  thvi  large  trochanter,  in  the  normal  position  of  the  femur.  It 
crosses  the  trochanter  more  or  less  below  the  apex  in  dislocation. 

In  applying  this  test  in  the  third  stage  of  morbus  coxarius,  you  will 
mostly  find  the  normal  relations,  or  so  insignificant  difference  as  to 
preclude  all  possibility  of  dislocation.  Irrespective  to  this  clinical  fact 
the  morbid  condition  of  these  points  contradict  the  assertion  of  Rust*m 
toto.     It  might  rather  be  said  that  the  acetabulum  becomes  dislocated, 


39 


since  we  often  find  it  extending  up,  and  backward  in  which  direction  the 
femur  fellows,  but  true  dislocations  belong  to  the  rarest  occurrences,  I 
have  searched  in  this  respect  the  anatomical  museums,  on  this,  and  the 
other  side  of  the  Atlantic,  without  having  found  more  than  about  a 
dozen  specimens,  exhibiting  the  conjoined  evidences  of  hip  disease  and 
dislocation.  In  this  statement  I  am  borne  out  by  other  enquirers.  It 
follows  therefore,  that  dislocation  is  but  a  rare  incident  in  hip  disease, 
indeed  much  more  so,  than  might  be  rationally  expected,  considering  the 
actual  state  of  the  joint  in  many  instances.  If  dislocation  is  practicable 
in  a  healthy  articulation,  how  much  more  predisposed  must  the  latter  bo, 
when  the  acetabulum  is  denuded  and  enlarged,  the  round  ligament 
totally  destroyed,  ihe  head  of  the  femur  dimininhed  in  size,  the  cotyloid 
cartilage  more  or  less  disintegrated,  the  capsular  ligament  broken  through 
&c. ;  which  all  tend  to  facilitate  the  displacement  of  the  femur.  It  is 
thus  evident,  that  the  slightest  appreciable  injury  should  suffice  to  bring 
about  a  dislocation,  but  its  spontaneity  cannot  be  conceived,  and  must 
therefore  be  denied.  On  the  other  hand,  it  must  be  borne  in  mind  that 
the  joint  being  more  or  less  tender,  is  well  taken  care  of  by  the  patient 
and  protected  against  incidectul  injuries. 

One  of  these  means  is  the  play  of  all  muscles  by  voluntary  effort  to 
keep  the  joint  at  rest,  and  thus  dislocations  are  prevented,  which  other- 
wise might  seem  inevitable.  Wherever  dislocations  take  place,  there 
can  be  no  doubt  as  to  their  being  the  result  of  some  injury  or  other, 
however  trifling.  That  much  I  can  at  least  assure,  that  I  never  myself 
have  had  the  opportunity  of  observing  a  single  case  of  indisputable  dis- 
location consequent  upon  morbus  coxarius,  and  I  have  had  my  finger  in 
the  hip  joint  too  often  to  be  deceived.  If  you  examine  a  patient  so 
afflicted,  with  the  aid  of  ana3Sthetics,  extending  the  affected  limb,  whilst 
at  the  same  time  exercising  counter  extension  by  placing  your  foot 
against  the  pelvis,  you  will  notice  a  certain  amount  of  mobility  of  ihe 
joint,  but  the  absolute  impossibility  of  abducting  it.  In  searching  for 
the  cause,  a  firm  and  unyielding  contraction  of  the  adductor  musch  s 
will  be  found,  over  which  the  anaesthetics  seem  to  have  no  influence 
whatsoever.  It  is  thus  in  the  third  as  in  the  second  stage,  the  malposi- 
tion of  the  l-.xiO  is  produced  by  a  single  cause,  and  the  rest  of  the  symp- 
toms follow  as  physical  necessities.  Now,  for  instance,  let  us  presume 
the  femur  held  in  undue  position  of  adduction  and  flexion,  and  the 
patient  attempt  to  walk,  he  would  yield  the  pelvis  as  much  as  possible 
for  th<3  purpose  of  relieving  the  tension  of  the  contracted  muscles.  The 
first  thing  he  does  is  to  rotate  the  pelvis  in  its  transverse  diameter,  thus 
approximating  the  anterior  superior  spinous  process  of  the  ilium,  to  the 


'  i 
!     1 


■n 


■J  I 


d 


40 


' 


M^ 


Mi 


I'   ! 
I*'' 


IP 

15.;  I 


insertion  of  the  tensor  vaginae  fcmoris.  This  accounts  for  the  enhanced 
unfile  of  inclination  witli  the  horizon.  By  turning  the  pelvis  on  its  axis 
at  the  lumbar  articulations,  the  patient  favors  the  former  object.  If  the 
pelvis  remained  (juite  horizontal  and  ths  e5:tremity  of  the  healthy  side  rec- 
tangular to  the  former,  the  aiTectcd  limb  would  necessarily  cross  its  fellow, 
and  locomotion  would  thus  be  rendered  impracticable.  Hence  the  affected 
side  of  the  pelvis  is  tilted  up  in  proportion  to  the  adduction  of  the  affect- 
ed extremity,  the  healthy  member  is  thrown  out,  (abducted)  and  paral- 
lelism is  thus  achieved.  If  tlie  pelvis  is  thus  out  of  position,  the  spine 
and  shoulders  have  to  adapt  themselves  to  the  static  changes. 

In  compounding  the  effects  of  these  changes  in  the  position  of  pelvis 
and  femur,  we  can  almost  to  a  nicety,  ascertain  the  amount  of  apparent 
shortening,  without  regard  to  the  so  called  spontaneous  dislocation.  The 
longitudinal  rotation  of  the  pelvis  will  raise  the  extremity  as  much  as  an 
inch,  the  flexion  of  the  femur  upon  the  pelvis,  another  inch,  and  the 
obliquity  of  the  pelvis  from  one  to  three  inches.  Thus  the  limb  may  be 
shortened  in  the  aggregate,  from  three  to  five  inches,  an  amount  never  to 
be  produced  by  traumatic  dislocation  oP  the  femur  upon  the  ilium. 

Most  cases  of  morbus  coxarius  terminate  with  the  third  stage ;  but 
comparatively  a  few  advance  to  the  fourth  and  last  stage  of  the  disease, 
■which  is  a  combination  of  the  symptoms  of  the  third,  with  those  of  caries, 
abscesses,  fistulous  openings  and  tracts,  in  the  neighbourhood  of  the  joint, 
local  pain,  arising  from  such  sources,  and  hectic  fever. 

Thus  it  will  be  seen  that  hip  diseiise  is  characterized  more  than  any 
other,  by  a  certain  immutable  regularity  and  chronological  succession  of 
symptoms,  which,  in  themselves,  furnish  the  strongest  ground  for  differ- 
ential diagnosis.  Though  the  first  stage  may  escape  the  vigilance  of  the 
professional  attendant,  the  second  will  inevitably  decide  his  appreciation 
of  the  growing  trouble.  The  third  stage  is  invariably  preceded  by  the 
second,  and  the  fourth  by  the  former  stages.  This,  at  least,  has  been 
my  observation  in  a  large  number  of  oases,  and  I  entertain  no  doubt  that 
it  is  substantially  the  same  with  other  accurate  observers.  The  excep- 
tions that  may  be  adduced  apertain.  to  cases  partly  not  hip  disease  at 
all,  partly  hip  disease  of  a  consecuti\'e  nature,  and  consequently  blended 
with  other  pathological  conditions; 

Periostitis  in  the  neighbourhood  of  the  hip  joint  often  produces  simi- 
larities of  hip  disease  of  a  most  striking  character.  We  may  find  in 
connection  with  it  all  the  symptoms  enumerated  under  the  third  stage  of 
morbus  coxarius,  but  this  difference  will  always  bo  manifest :  that  the 
symptoms  of  the  second  stage  never  preceded  that  condition.  If  the  joint 
is  not  secondarily  implicated  in  those  cases  there  will  be  a  freer  mobility 


m 


41 

of  the  same,  and  no  crepitus ;  whilst  on  the  other  hand,  the  femur  is 
enhirged  and  tender. 

Sometimes  we  meet  with  malposition  of  the  femur  in  consequence  of 
Potts'  disease,  and  periostitis  of  the  spine,  which  may  give  rise  to  an 
erroneous  diagnosis.  The  history  of  morbus  coxarius  and  affections  of 
the  spine  is  so  diftorentially  marked  that  the  mistake  may  be  easily  cor- 
rected. Eventually,  the  application  of  chloroform  will  suffice  to  overcome 
the  muscular  retractions  of  the  latter,  and  prove  the  hip  joint  to  be  in- 
tact. 

^V'e  owe  to   Erichscn's  careful  investigations,  our  knowledge  of  the 

suppurative  affection  of  the  sacro-iliac  junction,  but  the  symptoms  ad- 
duced by  that  author  are  so  widely  different  from  those  of  hip  disease, 
that  they  hardly  can  be  confounded.  Eventually  the  careful  examina- 
tion of  the  corresponding  hip  joint  must  necessarily  settle  all  doubts. 


IV. 


PROGiNOSlS  ON  JOINT  DISEASES. 


From  the  preceding  remarks  of  the  discourse  we  may  sum  up  the  fol- 
lowing prognostic  axioms. 

From  the  collective  character  of  joint  affections,  we  must  come  to  the 
conclusion  that  they  constitute  formidable  diseases. 

In  their  respective  courses,  they  ax*e  slow  aud  protracted,  often  of  year.'; 
duration. 

In  their  commencement  and  development  they  are  insidious,  and  may 
nave  proceeded  to  considerable  disintegration  of  normal  tissue  before  the 
patient  becomes  aware  of  the  impending  difficulty. 

The  restitutive  powers  of  some  of  the  articular  structures  are  of  an 
indifferent  character,  owintr  to  the  imperfections  of  their  nutrition. 

In  as  far  as  the  osseous  aructure  is  concerned,  recovery  depends  on 
the  gradual  destruction  of  the  affected  parts,  which  of  course  is  necessa- 
rily tedious. 

In  most  joint  diseases  the  affected  structures  undergo  changes  more  or 
less  disqualifying  them  for  the  performance  of  their  respective  physiolo- 
gical offices,  thus  cither  impeding  or  annihilating  the  usefulness  of  the 
articulation.     •  .  -, 

The  suppuration  of  articular  cavities  leads  to  their  perforation,  to  ex- 
tensive subfascial  burrowing  of  pus,  and  not  only  involves  the  extremity, 
but  the  constitution  at  large. 

Reflex  pains  and  spasms  accompanying  joint  diseases  are  of  the  most 


-11 


<i 


^1 


1;i;  ^^ 


4t 

violent  and  torturing  character,  upsetting  re  it  and  appetite,  placing  the 
very  existence  of  the  patient  in  jeopardy. 

Caries  of  the  articular  faces  may  cause  so  copious  a  drainage  as  to  gra- 
dually bring  the  patient  to  hectics,  pyaemia  and  multilocular  abscess  in 
the  vital  organs. 

Finally,  malposition,  deformity,  false  and  true  anchylosis  may  termi- 
nate these  diseases,  and  disable  the  patient  for  the  rest  of  his  life. 

All  this  should  be  borne  in  mind  when  taking  charge  of  cases  of  this 
description,  and  our  prognosis  should  be  guarded  under  all  circumstances, 
however  slight  and  insignificant  the  cases  might  appear  at  the  first  glance  ; 
for  the  objective  symptoms  are  not  a  reliable  barometer  of  the  actual 
condition  with  which  one  may  eventually  have  to  grapple. 

Notwithstanding  all  I  have  said  in  this  respect,  the  prognosis  of  joint 
diseases  is  infinitely  better  to  day  than  it  was  fifty  years  ago.  The  pre- 
sent generation  has  achieved  a  clearer  insight  into  the  physiological  and 
pathological  character  of  joints  than  our  professional  ancestors ;  it  has 
successfully  rid  itself  of  errors,  heresies,  and  notions  which  obscured  the 
unbiassed  clinical  understanding  of  this  class  of  diseases  ;  and  since  then 
we  have  steadily  improved  in  therapeutic  efficiency  and  self-reliance. 
What  was  formerly  awo/i  me  tangere,  has  become  a  coveted  object  of  dili- 
gent investigation  and  treatment.  And  the  results  of  our  cherished  efforts 
are  in  every  respect  gratifying  to  the  professional  pride,  and  afford  rea- 
sonable satisfaction  to  the  patients  concerned. 

It  will  scarcely  be  necessary  to  enter  into  prognostic  details,  inasmuch 
as  they  maybe  inferred  from  the  previous  section  of  these  lectures,  or  may 
be  yet  especially  alluded  to  under  the  succeeding  heading. 


il  ,1 


I 
11"' 


iREATMENT  OF  JOLNT  DISEASES. 


l*he  most  important  proceeding  in  this  direction  is  a  thorough  and 
systematic  examination,  comprising  both  the  antecedents  of  the  patient 
and  the  present  clinical  aspect  of  his  disease.  In  reference  to  the  for- 
mer, the  state  of  health  of  his  immediate  and  remote  ancestors  should  be 
ascertained,  as  it  might  possibly  affect  the  prognosis  of  the  case.  Next 
to  this  is  the  previous  history  of  the  patient,  whether  he  has  passed 
through  the  ordinary  infantile  diseases  without  sequelae  ;  whether  the  pre- 
vious state  of  his  qonstitution  and  'aealth  has  been  strong  and  vigorous, 
or  otherwise.  It  might  be  as  well  to  inquire  into  the  character  of  his 
temperament,  m3de  of  living,  residence,  domestic  surroundings,  &c.,  in  or- 
der to  form  an  approximitc  id  3a  as  to  the  status  and  vigor  of  his  system, 


■^1;! 


48 


A 


nd 

ent 
br- 
be 
xt 
ed 
re- 
lus, 
his 
or- 
m. 


The  next  object  of  inquiry  would  be  the  probable  causation  of  the  impend- 
ing disease.  In  this  respect,  gentlemen,  I  should  advise  to  be  searching 
and  persevering,  for  most  parents  know  so  little  about  it,  that  we  are 
obliged  to  sharpen  their  memory.  They  will  assign  the  most  trivial 
causes,  and  harp  upon  the  same  with  great  pertinacity,  simply  because 
the  true  occasion  is  in  the  past,  and  has  slipped  their  memory,  whereas 
trivialities  are  brought  forth  because  they  happened  at  a  time,  soon  after 
which  the  disease  assumed  form  and  importance.  I  have^been  startled 
by  the  simplicity  with  which  even  modern  writers  on  !he  subject,  have 
allowed  themselves  to  be  stultified  with  the  most  innocent  and  harmless 
occurrences,  as  for  instance  "  sitting  down  on  the  grass,"  or  "  on  a  cold 
stone,"or  "  having  run  about  a  good  deal,"  &c.  I  cannot  persuade  myself 
that  such  trivialities  can  constitute  legitimate  and  reasonably  acceptable 
causes  of  joint  diseases,  even  if  they  are  printed  over  the  signature  of 
a  respected  surgical  name. 

In  closely  investigating  further,  you  will  Icaru  that  there  have  been 
trjLiimatic  la/iuences  of  some  kind  or  other,  more  or  less  direct  upon  the 
articulation,  and  if  nothing  of  the  kind  could  be  traced,  I  would  not  hes- 
itate in  assuming  the  same,  if  the  previous  health  of  the  patient  had  been 
untainted  with  manifestations,  which  can  be  justly  ascribed  to  chronic 
nutritive  derangements  and  a  vitiated  domestic  atmosphere.  That  a 
traumatic  accident  has  by  weeks  and  even  months  preceded  the  actoal 
disease  is  no  argument  against  its  injury,  since  we  know  from  the  preced- 
ing remarks,  that  more  or  less  time  will  necessarily  intervene  betv/eeu  the 
accident  and  the  disease,  to  bring  about  those  changes  in  the  structures, 
which  can  attract  attention.  Moreover,  it  is  mostly  fhe  local  pain  and 
the  disturbance  in  the  I'se  of  the  joint,  before  any  notice  at  a!l  is  taken, 
and  either  of  them  are  uat  mere  retViOte  results. 

We  may  then  proceed  with  a  general  inspection  of  the  patient ;  his 
general  api)earance  ;  as  to  the  present  state  of  his  health,  and  the  actions  of 
the  respective  systems.  If  the  patient  presents  pallor,  general  attenuation, 
and  prostration,  you  may  rest  assured  that  the  disease  has  far  advanced, 
and  shaken  his  general  health  by  the  incidental  reactions  upon  rert,  appe- 
tite and  nutrition. 

The  patient  should  then  be  undressed  so  as  to  obtain  a  full  view  of  the 
articulation,  and  the  affected  member  in  general ;  we  oi  ght  to  note  its 
circumference  and  position,  and  compare  it  with  the  other  extremity ; 
nstitute  locomotion,  and  carefully  observe  how  the  joint  is  used  and  the 
limb  is  put  to  an  accoi  nt.  If  the  patient  should  limp,  we  ought  to  deter- 
mine whether  the  limping  depends  on  immobility  or  tenderness  of  the 
affected  articulation,  or  on  malposition,  or  deficiency  in  the  length  of  the 
member. 


■>lii 


•* 


]n 


11 


I'* 


'^ 


I      V. 


; 


;    ; 


I    it. 


In  fine  the  patient  should  be  placed  on  a  suitable  table,  so  as  to  be 
accessible  from  all  sides,  and  be  put  under  the  full  influence  of  an  anaes- 
thetic, that  volition  may  he  suspended  and  the  rest  of  the  examination  be 
painless.  These  preparations  I  regard  as  essential,  to  obtain  a  full  know- 
ledge of  the  character  and  extent  of  the  disease, 

T  do  not  deem  it  necessary  to  enter  into  the  full  details  of  the  examin- 
ation with  which  you  are  already  acquainted.  But  a  few  points  deserve 
special  attention.  In  the  first  place,  we  hav  to  ascertain  the  condition 
of  the  bones  constituting  the  affected  joints,  and  find  out  whether  the 
disease  has  originated  remote  from  the  joint,  in  the  periosteum  or  in  the 
bone  itself.  In  either  case,  we  shall  find  by  comparison,  that  the  circum- 
ference cf  the  bone  is  incrcised  and  the  adjacent  tissues  more  or  less 
infiltrated,  its  surface  be  uneven,  pressure  upon  it  be  tender,  and 
by  bending  the  bone,  we  occasionally  find  that  it  has  lost  its  elasti- 
city and  hardness.  We  have  next  to  direct  oit  attention  upon  the  con- 
dyles, compare  their  size,  elasticity  and  sensitiveness  with  the  correspond- 
ing condyles  of  thf  other  limb.  Frequent  practice  will  enable  us  to  dis- 
cern changes  which  are  easily  overlooked  and  ignored  by  the  novice^ 
There  is  a  certain  degree  of  elasticity  in  the  condyles,  which  is  lost  by 
the  morbid  alterations,  even  the  increased  tenderness  of  the  bony  struc- 
ture becomes  manifest,  though  the  patient  be  in  anaesthesia.  On  moving 
the  joint  carefully,  we  ascertain  the  degree  of  mobility  and  the  changes 
that  may  have  taken  place  in  the  articular  surfaces.  Polypiform  growths 
of  the  synovial  membrane  may  thus  be  discovered,  when  they  are  too 
small  for  the  touch  of  the  finger.  Crepitus  would  be  the  evidence  of 
destruction  of  cartilage ;  its  absence  proves  nothing  to  the  contrary,  as 
we  have  learned  on  a  former  occasion;  [f  the  joint  allows  an  undue 
lateral  or  rotatory  movement,  we  may  infer  that  the  lateral  or  interme- 
diate ligaments  have  become  destroyed^  and  if  combined  with  crepitus, 
it  may  indicate  that  the  articular  faces  have  been  materially  flattened 
and  changed  in  form.  If  the  periarticular  tissues  of  a  joint  arc  largely 
infiltrated,  and  the  joint  itself  is  either  dry  or  contains  but  little  fluid, 
we  have  the  more  reason  to  suspect  bone  disease,  and  centre  our  attention 
upon  the  condition  of  the  osseous  structure,  A  distension  of  the  articu- 
lar cavity  without  induration  of  the  periarticular  structures,  indicates 
synovitis. 

Durin<  ic  anaesthesia,  we  can  but  ascertain  whether  the  malposition 
ispuduced  by  interartic\^lai  adhesion  or  muscular  contractions,  or  both, 
and,  moreover,  whether  the  contracted  muscles  still  retain  tlieir  expansi- 
bility, or  have  more  or  less  lost  it.  If  there  are  sinuses  about  the  joint 
we  must  try  to  discover  their  course  and  termination,  though  they  may 


45 


be  very  circuitous.  I  have  found  pewter  and  elastic  probes  more  availa- 
ble for  this  purpose  than  silver  ones  ;  and  large  probes  I  etter  than  the 
finer  oras.  In  this  way,  gentlemen,  we  shall  arrive  at  a  clear  under- 
standing of  our  case,  and  establish  a  reliable  diagnosis  as  a  basis  of 
therapeutic  action. 

The  first  stage  is  the  disease  but  virtually.  The  aflfected  structures 
are  but  in  a  state  of  congestion  and  hyperaemia  with  incident  tenderness, 
there  are  no  substantial  changes  as  yet,  and  by  at  once  taking  prompt 
measures,  wc  may  succeed  in  obviating  future  mischief.  The  earlier 
this  is  done  the  surer  we  may  count  on  success.  Nay  more,  I  should 
consider  myself  justified  in  treating  every  injury  to  the  joint  as  a  virtual 
afiFection  of  the  same.  A  few  weeks'  restraint  is  notiiing  in  comparisvin 
with  those  terrible  maladies  that  may  eventuate  from  apparently  insigni- 
ficant causes.  But  with  all  the  precautions  imaginable,  and  with  the 
most  appropriate  and  prompt  treatment,  we  are  not  always  able  to  pre- 
vent the  C(msc(]uenccs,  more  particularly  il'  they  refer  to  injuries  of  the 
periosteum  and  the  bony  structure. 

The  vertj  first  ihemjmttic  axiom  in  the  treatment  of  joint  discuses  is 
rest,  ahsolutc  and  unconditional,  and  the  next,  proper  position  of  the 
affected  articulation.  The  efficacy  of  these  two  is  greater  and  more 
reliable  than  the  entire  antiphlogistic  appai'atus,  and  they  generally 
suffice  to  meet  the  exigencies  of  the  first  stai>'e. 

The  affected  joint  is  to  be  rendered  immovable  by  appr.^  iate  band- 
ages, materials,  or  special  appliances ;  and  if  the  affection  concern,  the 
lower  extremity  it  would  bo  additionally  advisable  that  the  patient  takes 
to  his  bed  and  thus  get  riJ  of  the  superincumbent  weight  upon  the 
affected  joint.  The  ordinary  way  of  rendering  a  joint  immovable,  is  by 
hardening  bandages,  by  leather,  gutta-percha,  wooden,  wire  or  light 
metallic  splints,  that  are  adapted  to  the  form  of  the  extremity.  If  the 
morbid  condition  of  the  joint  is  not  far  advanced,  so  that  we  maj'^  not 
require  to  inspect  the  articulation  often,  and  thus  disturb  the  dressing, 
stiflF  bandages  are  certainly  preferable,  othcrwi.se)  splints  should  be 
chosen.  The  stiff  bandages  are  made  by  impregnating  the  outer 
portion  of  the  dressing  with  flour,  etarcii,  or  dextrine-paste,  plaster 
of  Paris  or  the  liquid  glass.  Inasmuch  as  these  bandages  are 
more  or  less  impermeable  to  the  perspiration,  it  is  necessary  to  first 
surround  the  extremity  with  a  well  applied  flannel  bandage,  under  which 
the  unevcnness  of  the  surface  should  be  filled  with  cottonwool.  How 
the  rest  is  done,  is  indeed  very  indilfurent,  as  long  as  it  fulfills  its  object. 
Until  the  bai  dage  is  perfectly  dry,  it  would  be  advistible  to  fasten  a 
splint  to  the  member.     In  some  instances  it  maybe  advisable  previous  to 


■I 
i 


II 


i|: 


■•;l 


> 


m 


si 


il 


V 


i  1 


'  !**■ 


fi 


>      i' 


i-  iffli 
'  tr' 


-'  i 


■  I 


I! 


46 

the  application  of  the  bandage,  to  apply  an  appropriate  nun)ber  of  leeches^ 
so  as  to  reduce  the  hyperaeraia  and  stasis,  the  effects  of  which  are,  how- 
ever, but  transitory.  The  fixture  of  the  joint  should  immediately  follow. 
Except  in  recent  injuries,  the  application  of  cold  is  rarely  demanded,  but 
if  resorted  to,  it  should  be  efficiently  applied  in  the  form  of  ice  bags,  for 
which  purpose  one  part  of  the  joint  may  be  relieved  from  the  bandage 
and  exposed  to  the  action  of  that  remedy. 

The  position  of  the  aifected  joint  should  be  such  in  which  the  patient 
is  most  comfortable  and  at  rest.  It  is  chiefly  governed,  however,  by  the 
tendency  of  certain  muscles  to  contract,  and  therefore,  should  at  once  be 
placed  in  an  antagonistic  position.  If  you  remember  that  portion  of  our 
discourse  in  which  I  referred  to  muscular  contraction,  you  will  know  to 
choose  the  position  which  is  most  appropriate.  In  adopting  the  same, 
muscular  contractions  and  ma  positions  will  thus  be  obviated.  Some 
surgeons  advise  to  give  the  extremity  such  an  angle  as  will  be  most  con- 
ducive to  its  usefulness.  We  have  nothing  to  do  with  that  object  at  this 
juncture ;  our  object  is  to  relieve  the  disease  and  thus  preserve  the  entire 
usefulness  of  the  joint;  their  advice  is  in  place  when  the  joint  is  about 
anchylosing.  Tiie  straight  position  of  the  elbow  joint  gives  more  relief 
than  the  flexed  one,  irrespective  to  the  fact  that  the  latter  favours  the 
contraction  of  the  biceps  and  brachialis.  And  a  straight  limb  bears 
more  vertical  weight  than  a  bent  one,  and  may  be  used  to  greater  advantage 
in  locomotion. 

The  same  treatment  holds  good  in  perforating  wounds  of  the  joints* 
with  the  additional  rule  that  the  wound  be  carefully  cleaned,  its  margins 
properly  approximated  and  united.  In  this  way  I  have  seen  many  an  in- 
cised and  punctured  wound  close  by  first  intention,  without  any  inconve- 
nience whatsoever.  Different  is  it  with  torn  and  contused  wounds,  where 
the  first  intention  is  but  exceptional,  and  suppuration  the  rule.  Immobi- 
lity and  proper  position  of  the  joint,  fire  likewise  U  chief  indications 
here,  and  should  be  scrupulously  observed,  but  the  dressing  should  cir- 
cumvent the  wound  and  leave  it  accessible  to  local  treatment. 

In  using  dextrin.,  starch  and  plaster  of  Paris  bandages,  that  part  in 
the  neighbourhood  of  the  wound  would  be  protected  by  a  coating  of  var- 
nish so  as  to  render  it  unimpregnable  to  the  discharge. 

I  rather  prefer  to  secure  the  immobility  of  the  joint  by  wire  and  me- 
tallic splints  (tin  or  sheet  iron)  inasmuch  as  they  will  permit  the  use  of 
permanent  bath,  wliich  I  consider  invaluable  in  the  treatment  of  such 
wounds.  We  owe  the  introduction  of  this  remedy  to  B.  Langenbeck, 
to  whom  surgery  is  indebted  for  many  and  valuable  improvements.  If 
suppuration  of  the  joint  ensues,  you  will  do  the  most  for  tlie  recovery  of 


f 


'■"■'■,       47 

your  patient  by  giving  free  vent  to  the  discharge,  and  by  keeping  the 
suppurating  surface  in  a  very  clean  condition.  By  these  means,  and 
eventually  by  free  incisions  into  the  articular  cavity,  I  have  saved  many 
a  patient. 

There  is  hardly  any  necessity  for  medication,  unless  incidental  derange- 
ments demand  therapeutic  interference.  The  local  treatment  suffices 
to  check  and  ameliorate  the  articular  disease ;  time  and  patience  accom- 
plish the  rest.  Beyond  those  local  remedies  I  have  mentioned,  notiiing 
else  is  required  at  this  juncture.  From  painting  the  articulation  with 
tincture  of  iodine,  I  have  seen  no  benefit ;  and  fly  blisters  interfere  with 
the  fixture  of  the  joint,  cause  a  needless  irritation  to  the  patient,  and 
sometimes  give  rise  to  reflexed  muscular  contraction,  as  I  have  seen. 

In  the  second  stage  the  indications  of  treatment  become  more  diversi- 
fied. The  pathological  character  of  this  period  is  expressed  by  structural 
invasions  of  a  more  decided  nature  ;  by  more  copious  infiltrations  and  effu- 
sion within  the  joint ;  by  reflexed  pain,  muscular  spasm  and  consequent 
malposition;  and,  in  fine,  reactive  disturbances  of  the  constitution. 

If  the  patient  has  been  properly  attended  to  at  the  first  stage,  the  dis- 
ease will  but  rarely  advance  to  the  second,  and  if  the  local  affection  was 
of  a  nature  that  could  not  be  checked  in  its  advance  by  due  precautioi), 
the  second  stage  will  be  at  least  materially  mitigated  by  the  previous 
treatment. 

Assuming,  however,  that  the  patient  comes  under  your  charge  with  the 
full  pathological  and  clinical  force  of  the  second  stage,  the  same  remedies 
and  appliances  commend  themselves,  for  rest  and  position  are  the  im- 
perative axioms  whilst  the  disease  is  in  active  progress.  In  this  stage  the 
antiphlogistic  treatment  is  resorted  to  in  vain,  as  long  as  rest  and  position 
of  the  joint  are  disregarded,  and  the  limb  permitted  to  bend,  rotate,  or 
assume  any  prejudicial  posture.  Nay  more,  the  antiphlogistic  remedies 
even  fail  to  give  the  slightest  relief  or  to  alleviate  one  single  symptom  ; 
my  own  personal  observation  has  decided  this  fact  conclusively,  and  I 
do  not  entertain  the  slightest  doubt  that  other  surgeons  have  met  with 
the  same  negative  results.  But  in  securing  rest  and  position  to  the  af- 
fected articulation,  we  almost  instantaneously  give  relief  to  our  patient, 
and  initiate  progressive  improvements.  Having  done  this  it  rests  with 
you  whether  you  deem  local  depletion  and  the  application  of  ice  or  nar- 
cotic fomentation  additionally  necessary.  I  have  but  rarely  and  I  may 
say  but  exceptionally  needed  them,  although  I  mean  not  to  deny  the  fact 
that  the  distended  capillaries  may  temporarily  and  usefully  be  depleted 
by  leeches,  wet  cups  and  scarifications ;  the  effect  of  which  you  have, 
however,  to  render  permanent,  by  means  of  which  I  shall  soon  speak. 


• 


1 
i 


■  til 


lt 

1 

; 

! 

111 

!     ; 

!  i 

■Ml 


48 


''  Si 


If  the  aflfected  member  has  already  been  placed  in  malposition,  you 
have  promptly  to  reduce  the  same  to  insure  articular  rest.  This  should 
be  done  under  the  full  influence  of  ansestheties.  I  consider  chloroform 
better  than  ether,  and  equally  safe.  If  I  stated  the  number  of  chloroform 
applications  that  I  have  made  with  complete  safety,  it  might  be  considered 
as  grandiloquy,  and  as  a  slur  upon  professional  brethren  who  have  had 
the  misfortune  of  meeting  with  fatal  accidents.  My  )nind  is  free  from 
any  such  intention  ;  I  simply  state  the  facts.  Yet  I  cannot  divest  myself 
of  the  impression  that  many  accident  cases  might  liave  been  obviated  by 
the  use  of  a  proper  and  reliable  article^  by  descrimination  of  patients, 
and  due  care  by  the  administrator. 

Of  all  the  chli)roform  offered  for  sale  in  tlie  maiket,  I  deem  that 
of  Dr.  Sijuihb  of  Brooklyn  tlie  best  ;  it  is  always  of  the  same  purity  and 
specific  gravity,  of  the  same  physical  quality  and  physiological  action,  and 
I  use  it  with  perfect  confidence. 

The  mode  in  which  I  administer  chloroform  is  very  simple,  although, 
perhaps,  not  economical.  I  form  a  coarse  towel  into  a  short  and  wide 
funnel,  with  an  inch  opening  at  the  apex  for  the  free  access  of  air;  and 
look  more  upon  the  action  of  the  lungs  as  indicative,  than  upon  that  of 
the  heart.  At  the  very  moment  that  the  thoracic  res{)iration  ceases,  and 
the  diaphragmatic  suction  prevails,  I  suspend  '/lilorolbrm  iidialation, 
whether  the  patient  be  under  its  full  influence  or  not.  This  seems  to  be 
the  margin  of  its  legitimate  use,  beyond  which  the  danger  commences. 

Patients  addicted  to  the  copious  use  of  alcoholic  liquor,  and  those  that 
present  a  leuco-phlegmatic,  bloated  and  hydraemic  appearance,  are  not  fit 
recipients  of  chloroform ;  nor  would  I  deem  it  safe  to  administer  it  to  pa- 
tienls  with  a  weak  and  flat  pulse,  in  whom  the  propelling  power  of  the 
heart  is  more  or  le^s  impeded  by  the  fatty  degeneration  of  that  organ. 

It  has  been  my  ibrtune  almost  always  to  be  assisted  by  reliable  and 
experienced  men  who  watched  the  effects  of  the  chloroform,  and  did  not 
divide  their  attention  by  looking  after  the  operative  proceeding.  In  a 
few  instances  I  came  near  losing  my  patient  by  chloroform,  and  averted 
the  fatal  catastrophy  only  by  noticing  the  impending  danger  in  time. 
But  these  mishaps  were  clearly  traceable  to  that  carelessness  which  arises 
from  the  divided  attention  of  the  assistant. 

The  patient  being  under  the  full  effect  of  chloroform,  we  now  proceed 
to  reduce  the  malposition,  and  bend  the  limb  either  in  the  opposite  or 
intermediate  position  from  that  in  which  we  found  it.  If  we  meet  with 
resistance  we  liave  to  overcome  the  same  by  a  legitimate  effort  of  physical 
power.  1  would  not  hesitate  to  break  up  inter-articular  adhesions  if  they 
off"ered  opposition.     If  intra-articular  cflFusion  opposes  the  reduction  of 


49 

i  ■  ^ 

the  malposition,  I  would  certainty  perform  paracentesis  of  the  joint. 
If  muscular  cantractions  are  in  the  ^vay,  I  would  resort  to  myotomy  or 
tenotomy.  ^/ 

There  are  authors  who  oppose  every  and  all  interference  with  the 
position  of  injiaimd  joints,  as  downright  meddlesoiucuess,  and  as  re- 
prehensible surgical  practice,  and  advise  the  redaction  of  the  inflam- 
mation as  the  preliminary  step.  I  apprehend  that  their  advice  is  actuated 
much  more  by  traditional  fears,  in  interfering  with  inflamed  articu  a- 
tions,  than  by  experience. 

Unless  I  were  permitted  to  adopt  that  plan,  T  would  decline  all  res- 
ponsibility attached  to  the  treatment  of  any  joint  disease. 

I  have  already  stated  that  antiphlogistic  remedies  have  very  little  effect 
upon  the  inflamed  structure  of  a  joint,  and  none  whatever  if  the  articulation 
is  permitted  to  be  disturbed  in  its  needful  rest,  by  the  jerks  of  the  patient, 
or  the  spastic  oscillation  of  irritated  muscles. 

If  under  such  circumstances,  and  under  the  purely  antiphlogistic 
treatment,  the  disease  becomes  arrested,  it  is  in  spite  of,  and  not  by 
virtue  of  such  treatment,  and  probably  has  been  protracted  thereby.  I 
could  prove  this  by  uncountable  cases,  and  produce  the  individual  pa- 
tients to  prove  the  facts  by  their  own  stories.  JJut  such  evidence  is 
scarcely  needed  to  gentlemen  whose  own  ore  of  experience  will  furnish 
them  with  sutticient  aifirmative  facts. 

No  one  will  deny  the  beneficial  results  of  relieving  an  inflamed  ar- 
ticulation of  its  morbid  product,  provided  that  the  process  of  removing 
the  same  does  not  entail  additional  danger.  Mr.  Barwcll  docs  me  tlie 
honor  of  eulogising  the  operation  which  lias  benefitted  so  many  of  his 
patients. 

That  the  operation,  if  properly  performed,  is  harmless,  I  shall  prove 
to  you  on  a  future  occasion. 

The  division  of  muscles  for  therapeutic  and  orthopoedic  purposes  in 
joint  diseases  lias  met  with  an  unfair  adjudication.  Barwell,  Davis, 
Prince  and  other  writers  on  the  subject,  arc  in  toto  against  this  operation ; 
they  hold  that  extension  is  quite  suftieient  to  control  the  spastic  affection 
of  muscles  agitated  by  the  reflexed  cifects  of  joint  diseases.  My  ex- 
perience in  extension  in  the  aft'eotions  of  joints  is  certainly  not  inferior 
to  any  one  of  these;  gentlemen ,  and  perhaps  not  inferior  to  them  collective- 
ly. I  say  so  with  due  respect  to  the  literary  merits  of  these  authors. 
And  I  can  bring  forth,  if  required,  the  very  proofs  of  Dr.  D.ivis's  error  by 
cases  which  he  ha  1  treated  by  extension  for  months  in  suoccssiou  and 
in  his  very  establishment,  without  subjugating  the  muscular  resistance. 

Need  I  state  to  you  that  I  hive  availed  myself  with   avidity  of  all 


r 


i    i 


Ml! 


lis 


50 

suggestions  and  means  promising  aid  and  comfort  to  this  class  of  my 
patients  ?  And  it  would  surely  be  a  source  of  gratification  to  me  if  I  could 
consistently  and  truthfully  acknowledge  my  professional  indebtedness 
for  information,  valuable  or  practically  useful.  As  it  is,  I  am  impelled 
to  state,  that  I  have  derived  little  or  no  benefit  from  extension  j^er  se  in 
the  treatment  of  progressive  joint  diseases.  Whatever  benefit  I  have 
derived  from  it  at  all,  is  unquestionably  due  to  its  collateral  effect  upon 
jixing  the  affected  articulation. 

The  collective  experience  on  this  question  I  can  sura  up  in  the  follow- 
ing aphorisms. 

Ist.  Extension  cannot  part  the  inflamed  articular  surfaces,  for  which 
it  has  been  erroneously  designed  by  its  author. 

2nd.  Powerful  extension  is  perhaps  the  promptest  remedy  against  an 
ephemeral  muscular  spasm,  as  every  one  has  experienced  with  himself 
if  he  has  happened  to  be  suddenly  attacked  by  spasms  of  the  muscles  of 
the  calf,  but  it  cannot  be  relied  on  in  persistent  spastic  agitations  of  the 
muscles. 

3rd.  In  many  instances,  extension  will  not  only  fail  to  relieve  th^ 
spasms,  but  will  re-act  unfavorably  upon  the  violence  of  the  existing  joint 
disease,  if  persisted  in. 

4th.  The  division  of  the  contracted  muscle  is  the  surest  and  unfailin^r 
remedy. — 

The  most  violent  periods  in  the  course  of  joint  diseases  I  have  ob- 
served, in  consequence  of  keeping  a  retracted  muscle  on  the  stretch,  and 
nothing  short  of  division  would  give  relief,  though  many  things  ami 
the  most  stringent  antiphlogosis  were  vainly  tried  before. 

It  is  indeed  a  most  egregious  error  to  assume  that  the  division  of  con- 
tracted muscles  is  merely  of  mechanical  importance  ;  in  some,  as  yet 
physiologically  unexplained,  manner  do  the  contracted  muscles  relate  to 
the  existing  joint  disease.  The  retractions  never  appear  before  the 
disease  has  advanced  to  a  certain  degree  of  violence  and  structural  in- 
vasion, and  unless  overcome  in  an  effective  manner,  they  increase  to  ac- 
tual contracture.  In  all  these  cases  the  disease  is  necessarily  protracted, 
and  when  at  last  it  subsides,  the  contracture  remains  tliough  its  original 
cause  has  disappeared.  On  the  other  hand,  the  original  joint  disease 
may  be  reproduced  after  years  of  extinction,  if  the  contracted  muscles 
are  unduly  and  persistently  extended.  Some  cases  of  this  description 
are  but  too  lively  in  my  remembrance,  and  my  experience  on  this  sub- 
ject is  too  dearly  bouglit  to  be  ever  forgotten. 

From  all  this  it  follows  that  certain  muscular  groups  stand  in  vital  re- 
lation with  certain  joints,  one  actuating  and  irritating  the  other  through 


'■:i 


\ 


cl 

t( 

n: 

e: 
al 

ni 
T 
m 

Wi 

pc 

g« 
di 

I 

fif 
m 


51 


the  same  source  of  nervous  supply.     Hence  the  division  of  so  contracted 
muscles  has  a  vital  bearing  on  the  status  of  the  joint,  aside  from  the  mc- 


Fig.  1. 
chanical  relation.  In  this  view  we  have  to  judge  the  therapeutical  charac- 
ter of  the  operation.  Dieffenbach  already  suggested  the  antispostic  effect  of 
myotomy  and  tenotomy  ;  I  not  only  accept  his  view  as  correct,  but  from 
experience,  I  am  justified  in  enhancing  the  same,  that  in  joint  diseases 
at  least,  it  is  the  most  reliable,  prompt  and  unfailing  antiphlogistic. 

Having  suggested  and  practised  myotomy  as  an  antiphlogistic,  it  is  but 
natural  that  I  should  spread  before  you  the  grounds  on  which  it  stands. 
The  way  in  which  I  came  to  the  knowledge  and  appreciation  of  this  re- 
medy, was  simply  this;  acting  on  the  conviction  that  rest  and  position 
were  the  two  great  axioms  in  the  treatment  of  joint  diseases,  I  had  to  dis- 
pose of  muscular  resistance  as  best  I  could  ;  and  often  not  being  able  to 
get  rid  of  it  by  any  other  means,  I  resorted  to  division.  The  eflFects  of  the 
division  upon  the  arrest  of  the  joint  disease  being  strikingly  beneficial, 
I  gradually  included  the  same  as  a  remedial  agent.  A  practice  of 
fifteen  years  duration  of  this  operation  entitles  me  to  a  vote  on  its 
merits. 


in 

m 

■n '  1 


Hi 


'.    «! 


1- 

! 


»   'I 


rwmmm 


' 


t  ;i 


l!'i 


I    ! 


52 

More  than  in  the  first  stage,  rest  and  position  of  the  affected  joint  are 
requisite  in  the  second ;  and  it  is  in  this  where  special  apparatuses  are 
profitably  resorted  to,  to  accomplish  so  important  an  object.  In  hip 
disease,  my  wire  apparatus  has  not  yet  been  exceeded  by  any  later  inven- 
tion, I  place  it  before  you  for  inspection  [fig.  1],  You  will  see 
that  it  consists  of  a  heavy  wire  frame,  which  is  so  covered  with  wire 
webbing  as  to  fit  the  posterior  half  of  the  body,  from  the  axillary  cavity  to 


the  sole  of  the  foot.  There  is  an  opening  for  the  anus ;  the  foot  boards 
move  by  a  screw  and  bolts.  To  protect  it  against  the  corroding  influence 
of  urine  and  faeces,  that  part  of  the  apparatus  most  exposed,  should  be 
thickly  covered  with  varnish.  The  average  price  of  the  same  for  chil- 
dren is  fifteen  dollars  currency.  In  using  the  apparatus,  (fig  2) 
you  have  to  line  it  wi^h  cotton  or  other  wool  or  tow,  and  whilst  the  patient 
is  under  chloroform,  you  place  him  in  it,  and  fasten  by  means  of  flannel 
bandages,  body  and  limbs,  so  securely  as  to  insure  his  position.  If  you 
should  desire  likewfse  to  apply  cxten.sion,  for  greater  security  of  rest  and 
position,  you  may  f;pply  longitudinal  and  circular  strips  of  stout  adhesive 
plaster,  and  fasten  the  former  to  the  foot  board. 

Some  writers,  among  thorn  Mr.  Barwell,  have  challenged  the  originality 
of  this  invention,  and  boldly  pronounced  it  a  copy  of  Bonnet's  wire  appa- 
ratus. I  apprehend  that  Mr.  Barwell  has  seen  neither,  otherwise  he  could 
not  have  come  to  so  inapplicable  a  conclusion.     I  have   never  claimed 


53 


the  introduction  of  wire  into  surgery;  that  point  is  conceded.  Bon 
net's  apparatus  is  a  clumsy  and  unwieldly  contrivance,  produced  for  no 
other  purpoL  ban  ,o  raise  the  patient  by  means  of  pulleys,  in  such  a 
manner  as  to  obviate  painful  jarring ;  my  apparatus  is  an  improved 
Dzondi-Hagedorn  where  dirsct  extension  can  be  exercised,  whilst  the  coun- 
ter extension  rests  with  the  healthy  extremity  on  the  same  pricciple  whicli 
we  employ  in  having  our  boot  pulled  off. 

I  leave  it  for  you  to  decide,  whether  the  mode  of  extension  com- 
monly employed  in  hip  dise.ise,  offers  the  same  advantages  as  my 
apparatus. 

In  this,  position  and  rest  are  insured  ;  the  patient  can  pass  his  focces 
with  perfect  ease,  by  raising  the  lower  end  of  the  apparatus,  and  placing  a 
bed  pan  under  it.  You  can  carry  the  patient  from  one  place  to  the  other, 
put  him  in  a  carriage,  draw  or  drive  him  into  the  open  air,  and  thus  meet 
all  the  objections  that  have  been  raised  to  confinement. 

In  the  other  mode,  the  extension  is  a  fixture  of  the  bed,  but  what  is 
still  worse,  it  allows  the  patient  to  accommodate  him.self  to  the  position,  so 
as  to  render  extension  nugotory.  I  have  seen  the  patient  turn  right 
around,  with  the  perineal  band,  and  accomodate  himself  so  ingeniously  that 
the  malposition  became  as  bad  as  if  there  had  been  no  restraint  whatever. 
Davis,  Veddcr  and  Barwell,  -have  successively  suggested  portative  ex- 
tension apparatus  to  obviate  the  confiucment  of  the  patient.  The  ho- 
nor of  the  original  suggestion  is  entirely  due  to  Davis,  and  the  merits  of 
the  same  ought  to  be  liberally  accorded  to  him,  for  it  certainly  has  bro- 
ken the  ice  of  the  scrofulous  heresy,  and  paved  the  way  to  the  rational 
ideas  of  therapeutics,  which  had  hccn  pre viousUj  advanced,  but  disregard- 
ed up  to  that  time.  Sayre,  though  strictly  speaking, 
but  an  exponent  of  Davis,  nevertheless  deserves  some 
credit  for  the  adroitness  with  which  he  has  propagated 
and  popularized  the  instrument,  which  seemed  -  '  ~ve 
been  an  elephant  in  the  hands  of  the  inventor. 

Davis's  instrument  as  improved  by  Sayre  is  here 
shown  (fig.  3.)  But  all  the  before  named  apparatus  arc 
at  fault  in  one  essential  point  :  they  neither  fix  the 
affected  joint,  nor  do  they  prevent  the  adduction  of 
the  extremity.  The  an»ount  of  extension  exercised  by 
them  is,  moreover,  very  insignificant,  and  if  it  was  fifty 
times  as  much,  it  could  not  separate  the  articular  sur- 
faces of  the  hip  joint,  as  is  erroneously  claimed  by  their 
respective  authors.  Besides  they  depend  on  adhesive 
Fig.  3.         strips  for  their  fastenings,  which  do  not  stick  well  in 


Hi. 


H-  It' 


54 


•cold  weather,  and  easily  slip  in  warm.  Sayre's  modification  to  circum- 
vent the  affected  extremity  with  a  semicircular  addition  at  the  lower 
end  of  the  instrument,  so  as  to  gain  two  purchases 
and  two  fastenings,  was  an  acceptable  improvement^ 
in  the  adjustment,  but  no  more.* 

These  deficiencies  in  the  mechanical  construction 

of  portative  apparatus,  have  obviously  induced  An- 
drews of  Chicago  to  fasten  a  straight  steel  crutch  to 

the   boot,  allowing  shortening  and   elongation.     In 

appropriating  thus  the  foot  for  extension,  the  tuber 

ischii  for  counter  extension,  and  the  screw  as  the 

moving  power,  he  happily  supplied  a  desideratum  and 

got  rid  of  the  annoyance  aad   insufficiency  of  the 

adhesive  strips. 

1  had  seen  nothing  of  Andrews'  very  acceptable 

improvement  when  I  constructed  the  apparatus  which 
is  now  before  you  (figs.  4  and  5).  From  this  to  that 
which  I  now  use,  was  but  one  step  (figiv  6  and  7), 
it  needs  no  description  or  explanation,  its  construc- 
tion speaks  for  itself.  Not  knowing  the  chronolo- 
gical priority  of  either  Andrews'  or  my  appliance, 
I  will  concede  with  pleasure  this  honour,  if  such 
it  be,  to  my  diligent  co-hbourer  on  this  field  of  surgical  culture. 

My  instrument  affords  both  efficient  extension  in  a  vertical  line  and 
complete  fixture  to  the  joint,  wherein  lies  its  chief  usefulness.  For  two 
years  I  have  had  it  in  use,  and  it  has  given  me  the  fullest  satisfaction, 
in  promptly  responding  to  all  the  indications  that  can  possibly  be  realized 
by  such  a  contrivance,  and  above  all  it  has  guarded  against  the  re-short- 
ening of  the  adductor  muscles  once  divided,  which  so  often  happened  in 
my  practice,  wheti  I  used  Davis's,  Sayers's,  and  Vedders's  apparatus. 

That  of  Harwell,  I  know  but  from  its  illustration  ;  I  have  never  seen 
nor  used  it,  and  forego  an  opinion  on  its  merits. 

With  all  advantages  that  may  possibly  accrue  from  my  instrument, 
I  must  warn  against  its  premature  use  at  the  second  stage,  unless  the 
disease  has  substantially  subsided,  and  'you  intend  only  to  follow  up  the 
results  of  your  treatment  by  its  application  ;  the  superincumbent  weight 
is  too  much  for  an  inflamed  hip  joint,  even  when  supported. 


Fig.  4. 


'. 


I   ^ 


i  ■ 


*  The  latest  contrivance  of  this  kind  is  that  of  Dr.  Taylor,  of  New  York.  He 
needed  not  to  have  gone  to  the  expense  of  a  patent  (!)  because  it  offers  no  superior 
iniucemeiits  and  is  not  likely  to  be  employed  by  any  one  else. 


a 


6ft 


To  secure  the  rest  and  position  of  the  knee  joi  I  'generally  prefer 
iiietallic  splints  to  stiff  bandages.  Vou  can  handle  ti.eni  better  without 
jurring  the  joint;  you  can  leave  a  part,  or  the  entire  joint  free,  for  ob- 
servation and  local  appliances,  an('  lose  nothing  in  the  mechanical  effect- 
you  can  take  them  off"  and  re-apply  them  with  the  greatest  ease :  you 
Can  combine  extension  with  them,  give  it  inclined  plane,  &c.,  and  thus 
secure  all  the  advantages  for  your  patient  that  could  be  desired.  I 
generally  keep  a  set  of  these  splints  on  hand,  so  as  to  be  prepared  for 
emergencies.     The  price  is  but  trifling. 


.'I; 


One  is  a  simple  gutter  splint  (fig.  8)  for  simple  cases.  The  other  ha.s 
a  semicircular  deficiency  at  the  knee  joint  to  expose  one  or  the  other 
side  (fig  9).  The  third  con.sists  of  two  .splints  joined  by  intermediate 
iron  braces   designed  to  leave  the  knee  joint  entirely  free.  (fig.  10) 

By  drawing  bandages  from  one  side  to  the  other  across  the  knee,  a 
moderate  degree  of  anterior  pressure  may  be  exercised.  If  the  patient 
has  so  far  recovered  as  to  resume  locomotion  with  safety,  a  portative 
apparatus  of  an  approximate  efficacy,  should  be  subatitucd  for  the  metal- 


■m 


H' 


56 


11.  I 


I' 


lie  splint.  For  this  purpose,  stiif  bandages,  leather  or  gutta 
/^    -%jjj^  percha  splints,  or  a  special  contrivance  (figs.  11  et  12) 

1*  1)/      would  Cijually  answer.     The  last  consists  of  two  braces 

Vs^^__^i/  along  the  limb,  three  or  four  bands,  with  a  knee  cap 
made  of  buckskin.  If  the  patieut's  limb  is  much  attenu- 
ated and  cylindriform,  it  would  be  an  improvement  to 
connect  the  apparatus  with  the  boot,  so  as  to  prevent 
slipping. 

Sayre  has  introduced,  for  the  purpose  just  mentioned, 
a  portative  extension  apparatus  for  both  knee  and  ankle 
joint,  with  a  view  of  parting  the  aflFected  articular  sur- 
faces, and  thus  alleviate  pressure  upon  one  another.  JMy 
belief  is  that  such  an  object  is  unattainable  by  any  me- 
chanical contrivance,  and  moreover  superfluous. 

In  placing  an  affected  joint  in  such  a  position  as  to 
have  the  largest  possible  contact  of  the  articular  surfices, 
we  at  any  rate  diffuse  the  pressure,  if  it  actually  does 
exist.     Sayre's  knee  apparatus  can  only  be  used  when 
^^'    '        the  limb  is  fully  extended. 
In  order  to  perform  paracentesis  of  an  articular 

cavity,  the  rule  ought  to  be  observed,  to  place  the 

joint  in  such  a  position  as  to  drive  the  liquid  to  the 

most  accessible  spot.     At  the  hip  joint  this  is  at 

the  posterior    circumference   of    the   acetabulum. 

The  glutei  mu.scles  being  attenuated,  we  generally 

succeed  in  discovering  fluctuation  a^  that  particular 

place.     Whilst  the  surgeon  is  about  inserting  the 

trochar,  an    assistant   takes   hold   of  the  affected 

extremity,   and   rotates    it    inwards,  which    gives 

the   greatest   distension   to    the  posterior   wall   of 

the  capsule.     This  manoeuvre  not  only  facilitates 

the  entrance    of  the  instrument,  but  likewise  the 

exit  of  fluid,  and  prevents  the  entrance  of  air. 
At  the  knee  joint  we  have  to  procure  first  a 

straight  position,  which  drives  the   entire   liquid 

into  the  anterior  portion  of  the  joint,     By  means 

of  a  tightly  applied  flannel  bandage,  commencing 

at  the  toes,  we  obviate  oedema  ;  the  joint  is  then 

surrounded  with  stout  adhesive  straps,  from  the 

tuberosity  of  the  tibia,  to  beyond  the  patella;  the 

unevenness  of   the  joint  being    previously  filled  pj     ,^ 


57 


with  graduated  compresses  ^r  witli  cotton.  Tlius  tlie  licjuid  is  driven 
to  the  cul  de  sac,  where  it  is  easy  of  access. — That  place  in  the 
cul  de  sac  between  the  duplicature  of  the  vagina  fenioris  and  the 
tendon  of  the  biceps,  is  most  avaihible,  there  being  no  muscular 
structure  interposed.  Having  thus  well  prepared  the  articulation, 
you  will   easily  enter  with  the  instrument,  and   the  liquid  will  rush 


out  through  the  canula  with  great  velocity  :  by  moving  the  finger  across 
the  distended  portion,  you  still  more  facilitate  its  exit,  and  with  the  same 
finger  close  the  wound,  while  the  other  hand  withdraws  the  canula. 
I  have  thus  in  numerous  instances  entered  the    articular  cavity,'  and 

repeatedly  the  same  articulation,  without  having  caused  in  a  single  in- 
stance reactive  trouble,  scarcely  ever  failed  to  give  instantaneous  relief 
to  the  joints,  although  in  many  cades  bv.^  temporarily. 


This  is  the  same  proceedure  which  I  invariably  adopt,  in  the  treatment 
of  hydrarthrosis,  and  which  has  proved  in  ray  practico  a  r^ry  reliable 
method. 

Puncture  of  the  joint,  in  these  cases,  has  been  unjustly  abandoned  by 
the  best  surgical  authorities,  (among  others,  Nelaton)  who  considers  it 
dangerous,  inasmuch  as  there  is  not  sufficient  centrifugal  pressure  of  the 


Fig.  10. 
liquid,  to  prevent  the  entrance  of  air,  for  he  states  most  emphatically 
that  the  inter-articular  fluid  runs  out  slowly  and  never  entirely.  ^.  By  the 


■ill' 


i 


.iiii 


63 


II 


plan  just  advanced  we  overcome  all  difiiculties  and 
dangers,  thus  ori*e  of  the  objectiors  may  be  considered 
disposed  of.  The  other  concerns  its  efficiency ;  in  this 
respect,  I.  can  but  state,  that  with  the  exception  of  one 
single  case,  I  have  radically  relieved  twenty-seven  cases  ; 
one  by  three,  two  by  two,  and  the  balance  by  one 
puncture.  Of  course  I  have  continued  compression  of 
the  articulation  for  some  weeks  after  the  operation.  All 
the  cases  operated  on  were  protracted  ones  of  not  less 
than  three  months,  and  the  majority  of  more  than  a 
year's  standing. 

This  plan,  then,  compares  very  favourably  in  point  of 
dispatch  and  efficacy,  with  any  other  I  IcuonV  of,  and 
certainly  is  not  as  hazardous  as  the  injections  suggested 
and  practised  by  Bonnet  and  Nelaton. 

Compresnon    of  affi^cted  joints  is   one    of  the  most 

estimable   auxiliaries   in   their    treatment,   and   should 

be  resorted   to  wherever   it   is  practicable ;    but   when 

Fig.  11.         resorted   to,    it    should    be    thorough    and     decided. 

Whether  the  substance  employed  for  compression 

has  any  additional  virtue,  and  whether,  therefore,  \ 

porous  or  impermeable  substances  should  be  used,    | 

I  am  not  as  yet  decided ;  my  experience  is  almost   1^^ 

entirely  confined    to  the  use   of  adhesive  plaster 

spread  on  Canton  flannel,  on  account  of  its  plia- 

bility   and   durability;   and  I  have  been  satisfied 

with  the  usefulness  '^/f  these  substances. 

When,  in    spite  of  this  treatment,  the   disease 

should  advance,  the  articular  cavities  become  more 

and  more  distended,  and  the  tendency  to  disruption 

is  manifest,   then   the   question  of    free    incision 

arises. 

Gentlemen,  I  am  most^anxious  to  put  my  views 

on  this  question  so  definitely  on  record,  as  to  leave 

no  doubt  as  to  their  bearing  and  meaning :  there- 
fore, I  wish  to  be  understood.   First.  That  I  do  not 

advise  nor  practice  any  meddlesomeness  with  joints 

at  all,   unless  the  strongest    indications  prevail. 

Second.  A  moderate  quantity  of  liquid  within  the  pjg  12. 

articular  cf.vity,  whether  this  liquid  be  essentially  synovia,  or  plastic  or 


59 


=^i 


purulent  effusion,  is  no  indication  per  se^  to  puncture  a  joint,  for  the  two 
former  liquids  may  readily  be  absorbed  and  got  rid  of,  and  so  may  pus 
by  previously  undergoing  a  fatty  degeneration.  I  have  met  with  such 
cases,  and  but  lately  the  joint  of  one  of  my  patients  opened 
in  the  middle  of  the  thigh,  from  which  I  could  squeeze  a  large 
quantity  of  pus,  fragments  of  cartilage  and  other  detritus,  which 
had  for  months  painlessly  occupied  the  joint,  and  had  completely  under- 
gone fatty  degeneration.  Tklrdh/.  I  puncture  the  articular  cavity  if  the 
effusion  is  progressive,  the  distension  of  the  joint  very  painful ;  and  for 
the  purpose  of  red  icing  an  existing  malposition,  provided  the  latter 
depends  in  part  or  m  toto  on  the  presence  of  intra-articular  effusion. 
Fourthly.  I  open  affected  joints  by  free  incisions,  when  progressive  sup- 
puration of  the  internal  articular  surface  exists,  and  threatens  disruption 
of  the  capsular  apparatus. 

If  I  am  not  mistaken,  my  esteemed  friend,  John  Gay,  Esq.,  of  the 
Oreat  Northern  Free  Hospital  of  London,  has  first  claimed  the  legitimacy 
of  this  operation,  and  received  a  goodly  share  of  abuse  for  it.  I  have  to 
offer  but  a  few  remarks  on  the  usefulness  of  free  incisions.  The  very 
essence  of  surgical  wisdom  is  to  imitate  nature,  and  to  avail  ourselves  of 
similar  means  for  certain  purposes.  In  suppuration  the  joint  is  first  dis- 
tended to  its  utmost  capacity  by  pus,  and  then  spontaneously  opened, 
and  the  matter  forced  into  the  adjacent  tissues.  The  ordinary  place  of 
perforations  is  near  the  bone,  sometimes  in  part  below  the  periosteum, 
mostly  under  the  respective  taseiae  of  the  extremities,  into  the  interstices 
of  the  muscles,  and  along  the  bone ;  additional  destruction  is  thus  caused. 

If  a  joint  disease  has  acquired  this  character,  the  joint,  as  such,  ceases  to 
exist :  al)  the  structures  constituting  the  internal  suiftice  undergo  patho- 
logical changes,  which  mostly  admit  of  no  reconstruction  ;  the  articular 
cavity  is  simply  an  abscess,  and  should  be  treated  as  such.  The  old  sur- 
gical axiom  "  ubi  pus  ibi  evacua,"  has  received  its  qualification  by 
modern  surgery,  but  its  full  sway  must  be  recognized,  whenever  the  abscess 
manifests  its  tendency  to  spontaneous  opening.  For  if  we  have  to  choose 
between  the  alternative  of  spontaneous  perforation,  and  its  uiulesirable 
sequelae,  and  free  incisions, — no  surgeon  can  hesitate  in  his  prcf  jronco. 
Sometimes  it  might  be  advisable  to  puncture  the  joint,  and  even  repeat- 
edly, with  a  view  of  obviating  the  danger  of  spontaneous  disruption ;  but 
if  the  latter  present  ^i  itself  in  unmistakeable  signs,  we  should  not  hasitate 
in  changing  the  artu  .-tr  cavity  into  an  open  abscess,  and  give  free  vent 
to  its  contents.  Hancock,  of  London,  claims  exsection  of  the  joint  as 
preferabk  to  free  incisions,  being  more  efficacious  and  less  dangerous. 
There  is  some  conditional  truth  in  this  proposition,  well  deserving  con. 


1 


■iil 
I' 


l!!^ 


bui^uiaBSB 


60 

sideration.  If  you  freely  open  a  joint  and  find  pathological  changes, 
beyond  those  of  simple  suppuration,  as  for  instance,  extensive  caries  ;  the 
sequestration  of  a  bone  ;  the  partial  or  total  destruction  of  intra-articular 
ligaments  and  cartilages ;  in  fact,  changes  that  would  require  many  months 
to  overcome,  exsection  of  the  joint  would  be  infinitely  preferable,  in  such 
case  the  free  incision  would  be  the  initiatory  step  towards  it.  On  the 
other  hand,  if  the  joint  is  in  a  condition  of  simple  suppuration,  so  that 
the  closing  up  of  the  articular  cavity  by  granulation  might  be  safely 
relied  on,  the  free  incision  will  suffice.  In  fact,  both  are  distinctly  dif- 
ferent remedies  for  distinctly  diflforent  purposes,  and  one  cannot  be  sub- 
stituted for  the  other. 

Having  laid  down  the  general  principles  for  the  second  stage  of  joint 
diseases,  we  may  now  refer  to  a  few  special  points.  One  of  ihcm  is  the 
treatment  of  subperiosteal  extravasation  or  effusion ;  another,  the  special 
treatment  of  those  nccrobiotic  disintegrations  of  one  or  the  other 
condyle,  to  which  I  have  adverted  in  another  part  of  our  discourse. 
The  management  of  the  former  is  very  plain  :  a  subcutaneous  division 
may  give  all  the  needful  relief,  and  stop  the  impending  trouble,  at  any 
rate  prevent  its  increase.  The  other  is  of  a  more  subtle  character,  re- 
quiring a  clearly  established  diagnosis,  settled  therapeutical  principles, 
and  consistent  action.  How  to  arrive  at  the  Hrst  I  have  already  indi- 
cated, and  to  render  the  diagnosis  still  more  conclusive  the  use  of  an 
explorative  trochar  would  bo  advisable.  If  we  have  become  thus  satisfied 
of  the  nature  of  the  complaint,  trephining  by  a  small  instrument,  and 
the  subsequent  scooping  out  of  the  disintegrated  tissue,  is  the  most 
direct  and  le^;itimate  remedy.  I  must,  however,  confess  that  I  have,  but 
in  a  few  cases,  resorted  to  this  operative  proceedurc,  though  with  marked 
success ;  my  personal  experience  is  therefore  limited,  but  it  would  seem 
the  most  appropriate  and  direct  remedy  when  a  clear  diagnosis  can  be 
obtained. 

In  summing  up  the  treatment  of  the  second  stage  of  joint  diseases, 
you  will  perceive  that  I  rely  exclusively  on  local  appliances  with  a  view 
of  obtaining  Jlrst,  rest  and  position  of  the  aifccted  articulation.  In 
procuring  these  I  have  occasionally  to  divide  resisting  muscles  and  to 
puncture  joints. 

Second. — Compression  of  the  inflamed  structures. 

2hird. — Paracentesis  and  free  incisions  in  joints  when  suppuration 

prevails.  ■ 

Fourth. — In  dividing  periosteum,and  in  removing  disintegrated  bony 
structure  by  trephine  and  scoop.* 

•  Kirkpatrick,  Medical  Press  and  Circular,  Dublin,  Aug.  21st,  1867,  recom- 
mends the  use  of  cscharotics,  especially  potassa  c.  calce,  for  the  same  therapeutic 
object,  and  relates  most  beneficial  results. 


■ 


61 


In  the  second  stage  of  this  class  of  diseases,  we  have  often  to  deal 
"with  violent  constitutional  disturbances,  which  are  more  readily  overcome 
by  proper  local  treatment  than  by  any  other  devised  medication,  never- 
theless the  utmost  attention  should  be  given  to  proper  diet  and  hygiene, 
which  is  the  more  necessary  as  all  the-;e  cases  are  more  or  less  protracted, 
and  therefore  more  or  less  bear  upon  the  constitutional  vigor. 

Now,  gentlemen,  let  us  contrast  the  treatment  just  described  with  the 
measures  of  the  old  school.  Ours  is  mild  when  compared  with  the 
barbarous  derivatory  appliances.  Moreover,  ours  is  effective ;  the  other 
is  worthless.  By  our  treatment  the  joint  is  placed  in  a  condition  of  spon- 
taneous recovery.  The  other  proposes  to  subjugate,  by  direct  means,  a 
disease  over  which  it  never  had  nor  could  exorcise  any  positive  influence. 
Nor  is  this  all ;  by  applying  the  actual  or  potential  ciiutjry,  nesv  troubles 
are  superadded  and  new  t;ixition  is  imposed  upon  an  already  overtaxed 
constitution. 

But  derivation  is  not  only  barbirous,  useless,  and  obnoxious,  it  is  even 
inconsistent  with  tlie  very  pretensions  for  which  it  is  used.  Supposing 
tubercular  depositions  are  at  the  bottom  of  a  joint  disease,  these  deposi- 
tions are  either  latent  and  innocuous,  or  they  act  like  any  other  foreign 
substance  in  creatinu;  circumferential  inflammation  with  a  view  of 
eventual  elimination.  In  the  former  proposition,  we  know  nothing  what- 
ever of  the  presence  of  those  depositions ;  simply  because  they  give  no 
trouble.  If  we  could  possibly  anticipate  the  time  when  such  tubercular 
depositions  would  be  likely  to  take  place,  then  derivation  might  be  relied 
upon  as  a  preventive  of  the  impending  danger. 

But  since  we  have  quietJy  to  wait  until  the  so  called  tubercular  depo- 
sitions are  formed,  and  until  they  are  undergoing  the  process  of  soften- 
ing and  compromising  the  surrounding  structures,  there  is  not  even  a 
pretence  of  reason  to  employ  derivation,  just  as  little  as  if  any  other 
foreign  substance  was  lodged  within  the  precinct  of  the  organism.  It  is 
claimed  that  tubercle  is  not  only  without  organization,  but  even,  not 
susceptible  of  it :  derivation  can  therefore  exercise  no  action  upon  the 
tubercle  itself ;  that  much  must  be  logically  admitted.  Can  it  prevent 
the  disintegration  of  the  adjacent  structures,  and  re-establish  their  former 
type  ?  of  course  not ;  then  what  is  to  be  expected  from  derivation  at  all  ? 

The  progress  of  pathology  has  been  most  fruitful  in  recognising  the 
existing  physiological  laws  which  govern  alike  health  and  disease.  The 
most  reliable  observers  tell  us  that  inflammations  once  set  up,  will  run 
their  course  to  their  termination,  whether  medication  be  imposed/or  not. 
The  idea  of  bringing  a  recent  pneumouia,  bronchitis,  pleuritis  or  a 
oatarrh  of  the  air  passages  to  an  abortive  end  has  been  so  tlioroughly 


•.f^'    i 


i 


t    I 


I 


62 


u     ^■- 


ffl 


exploded  that  no  wise  practitioner  follows  any  other  than  the  expectant 
method  of  treatment,  and  Hughes  Bennett  has  earned  for  himself  a 
lasting  distinction  in  proving  that  fact  by  clinical  statistics.  If  you 
concede  the  fact  you  have  to  accept  the  inferences,  that  is  to  say,  if  you 
cannot  cut  off  or  shorten  the  course  of  a  recent  disease  by  any  means  ; 
what  can  you  hope  to  do  in  cases  of  long  standing,  in  structural  disin- 
tegrations, and  more  particularly  then,  when  the  cause  (tuberculosis)  is 
persistently  at  work. 

It  will  be  equally  easy  to  demonstrate  the  utter  uselessness  of  deriva- 
tion in  the  primary  affections  of  the  synovia!  lining.  In  the  mildest 
form  of  them  (hydrarthrosis)  there  is  a  degeneration  of  the  synoYial 
membrane  which  Johannes  Muller  describes  as  lipoma  arborescens, 
which  is  fully  compatible  with  the  increase  of  the  natural  secretion,  but 
in  which,  however,  the  absorbent  powers  seem  to  be  entirely  lost.  Next 
you  have  the  so  called  catarrh  of  the  synovial  lining  in  which,  according 
to  Volkman,  the  epithelium  is  partly  thrown  off,  partly  converted  into 
pyogenic  source  :  there  you  have  morbid  secretion  and  loss  of  absorption. 
And  if  you  have  to  deal  with  a  more  parenchymatous  suppuration  of  the 
membrane,  you  have  no  longer  synovial  membrane,  but  a  luxuriantly 
granulating  and  secreting  surface,  with  very  doubtful  absorbing  endow- 
ments. 

The  restitutio  ad  integrum  is  absolutely  conditional  to  the  re-establish- 
ment of  absorption,  and  this  is  a  question  of  time.  Can  you  reach  or 
overcome  such  a  difficulty,  by  blistering  or  any  other  derivant  applied  to 
the  external  surface  of  a  joint  ?  Certainly  not ;  like  in  pleuritic  or 
pericarditic  effusions  you  have  either  to  tap  or  patiently  wait. 

I  do  not  want  to  enter  more  deeply  into  the  discussion  of  the  thera- 
peutic value  of  derivation,  heretofore  unduly  praised  and  over  estimated. 
All  I  propose  is  to  make  a  few  hints  and  suggestions,  and  leave  the  rest 
to  your  mature  deliberations. 

In  the  third  stage  of  joint  diseases  we  have  still  more  to  deal  with  both 
extensive  and  continued  changes  in  which  mostly  all  the  component  parts 
of  the  articulation  are  compromised.  In  whatever  tissue  the  malady  might 
have  started,  in  its  progress  it  has  comprised  the  rest.  Thus  in  synovitis,the 
articular  cartilages  have  been  exposed  to  constant  maceration  of  pus,  and 
have  suffered  those  elementary  metamorphoses  to  which  I  invited  your 
attention  on  a  prior  occasion.  And  when  at  last  they  drop  off  in  rags  and 
fragments,  the  osseous  surfaces  of  the  epiphyses  are  iu  turn  subjected  to 
the  same  obnoxious  actions. 

With  the  progress  of  their  disintegration,  the  periarticular  structures 
become  more  or  less  invaded  and  gradually  manifest  conditions  very  si- 


es 


niilar  to  those  of  white  swelling.  If,  on  the  other  hand,  the  primary  af- 
fections of  the  periosteum  and  epiphysis  proceed  to  the  perforation  of  the 
articular  cavity,  it  is  self-evident  that  its  lining  must  suffer  appropriate 
alterations.  The  third  stage  is  consequently  a  disease  of  the  entire  arti- 
culation, and  its  treatment  a  formidable  object  of  the  healing  art. 

Notwithstanding  the  undeniable  difficulties  of  these  affections,  quite  a 
large  proportion  of  the  patients  recover  with  or  without  aid,  and  some- 
times under  domestic  surroundings  of  the  humblest  kind  ;  whereas  others 
run  their  course  to  destruction  in  spite  of  therapeutic  efibrts  and  hygienic 
advantages.  The  reason  of  this  difference  is  not  always  apparent.  Oc- 
casionally the  abscess  determines  where  the  joint  gives  way  to  the  centri- 
fugal action  of  the  pus.  If,  for  instance,  the  pus  escapes  through  the  floor 
of  the  acetabulum,  it  spreads  over  the  internal  surface  of  the  pelvic  bones, 
by  detaching  the  periosteum,  and  may  eventually  make  its  appearance 
below  Poupart's  ligament,  or  through  the  ischiatic  notch,  or  between  the 
gluteal  muscles.  Irrespective  to  the  lesion  of  the  hip  joint  itself,  this 
condition  alone  would  constitute  a  frightful  disease,  sure  to  terminate 
disastrously.  Similar  complications  may  occur  with  other  joints  and  ag- 
gravate their  respective  diseases. 

The  indications  of  treatment  diversify  with  the  complications  present- 
ing. Generally  speaking  the  same  therapeutic  rules  come  into  play  at 
this  juncture  which  have  been  already  detailed.  Rest  and  position,  ex- 
eroisi,  even  in  these  aggravated  cases  of  joint  disease,  their  beneficial  in- 
fluence, but  the  appliances  should  be  portative  so  as  to  allow  the  patient 
the  conditional  enjoyment  of  open  air  perambulations.  Of  these  the  pa- 
tient is  greatly  in  need  to  sustain  his  constitutional  standard.  The  ap- 
pliances should,  moreover,  be  such  as  would  not  be  easily  saturated  and 
soiled  by  the  discharges.  James  Startin's  suggestion  to  impregnate  the 
bandages  and  splints  of  felt,  with  an  equal  mixture  of  melted  paraffine 
and  stearine,  for  the  double  purpose  of  stiffening  and  rendering  them 
watertight,  is  certainly  deserving  of  attention. 

I  have  not  as  yet  employed  this  material,  but  it  seems  to  me  preferable 
to  varnish  coating  heretofore  used. 

It  is  self-evident  that  the  fixture  of  the  joint  is  an  essential  disideratum 
to  prevent  the  corroded  surfaces  of  the  epiphyses  from  grinding  upon  one 
another,  and  thereby  give  rise  to  pain  and  renewed  irritation. 

The  fistulous  openings  should  be  maintained  and  their  drainage  kept 
free.  This  is,  however,  no  easy  task,  because  their  sinuses  are  very  cir- 
cuitous, and  dilatation  by  laminaria  or  compressed  sponge,  impracticable. 
The  laying  open  of  the  tracts  by  the  knife  is  mostly  of  but  temporary 
assistance,  incurring  loss  of  blood  which  patients  can  scarcely  bear.    The 


fif 


H 


I 


!i: 


employment  of  potassa  ^-  calce  (Kirkpatrick)  to  open  direct  communica- 
tion between  the  articular  cavity  and  the  surface,  deserves  surgical  con- 
sideration. 

Abscesses  freciuently  form  in  the  circumference  of  joints.  Those  which 
are  attended  witli  great  swelling,  pain  and  fevei',  and  indicate  the  efforts 
of  nature  to  eliminate  structural  detritus,  should  be  promptly  and  fully 
opened  ;  those  which  appear  more  or  less  remote  from  the  articulation 
and  cause  no  local  or  general  inconvenience  (cold  and  consecutive  abscess : 
abscessus  congCKtionis)  may  be  ignored  as  long  as  they  do  not  raise  alarm 
by  their  si/e  and  pressure  upon  important  parts.  Their  contents  readily 
undergo  iatty  degeneration,  followed  by  gradual  resorption.  But  if  they 
require  opening  it  should  be  done  by  trochar  with  the  exclusion  of  air. 
The  knife  should  only  then  be  employed  when  air  has  entered  the  pyoge- 
nic cavity,  and  decomposed  its  contents.  In  this  way  septicaemia  with 
its  fatal  consequences  can  be  averted. 

With  a  view  of  bringing  about  a  more  decided  detachment  and  dimi- 
nution of  the  structural  detritus,  various  means  have  been  recommended. 
John  Gay  insists  upon  free  incisions  into  the  affected  joint ,  others  allege 
they  have  successfully  employed  the  seton,and  Kirkpatrick  favours  an  open- 
ing with  his  escharotic  into  the  joint  and  uses  it  freely  upon  the  osteopo- 
rotic ubstancc;  and  finally  exscction.  The  two  former  apply  only  to 
superficial  and  accessible  joints,  and  all  four  are  necessarily  followed  by 
copious  suppuration.  They  are  therefore  but  available  in  well  preserved 
constitutions,  and  in  superficial  caries  of  the  articular  fiices. 

It  is  obvious  that  no  debilitated  patient  can  pass  unharmed  through 
.-^o  consuming  an  ordeal.     As  to  exscction  I  beg  to  submit : 

I.  That  if  a  thick  slice  is  removed  from  the  epiphyses,  we  approxi- 
mate the  cartilaginous  disks  fastening  them  to  the  shaft,  which  may 
thus  become  involved,  protract  and  even  prevent  the  reunion. 

II.  That  if  we  comprise  the  cartilaginous  disks  in  the  operation,  the 
extremities  become  so  much  shortened  as  to  render  the  result  nugatory, 
and  the  artificial  leg  preferable. 

III.  That  the  exscction  of  single  tarsal  and  carpal  bones  is  but  very 
exceptionally  attended  with  good  results  on  account  of  the  existing  inter- 
communication of  the  tarsal  and  carpal  joints. 

The  arrest  in  the  growth  of  extremities  operated  upon  by  exscction,  as 
observed  by  Koenig  of  Hanau,*  is  probably  founded  on  error  and  should 
not  prevent  us  from  resorting  to  so  legitimate  an  operation  in  its  proper 
place.  The  growth  is  impeded  by  the  previous  disease,  a  fact  most  pro- 
bably ignored  by  that  author. 

*  Arcliive  of  Clinical  Surgery,  Berlin,  18G7. 


05 


From  these  remarks  it  appears  that  exsection,  as  well  as  amputation, 
has  its  defined  therapeutic  value,  and  one  cannot  well  be  substituted  for 
the  other  without  risk  and  injury  to  the  patient.  1  have  nothing  t.  do 
Avith  the  technicalities  of  either  operation  at  this  juncture. 

Permit  me,  however,  to  tender  my  advice  in  reference  to  two  points  in 
exsection. 

I.  Before  proceeding  with  the  operation,  overcome,  if  possible,  the  ex- 
isting malposition  by  dividing  the  contracted  muscles.  I  have  mostly 
taken  these  preparatory  steps  and  thereby  secured  perfect  control  of  the 
subsequent  position  of  the  extremity.  I  owe,  perhaps,  to  the  observance 
of  this  preliminary  measure,  the  happy  results  that  have  attended  my 
operations,  more  particularly  at  the  knee  joint.  Whereas  some  of  my 
surgical  friends  who  neglected  it,  had  great  trouble  to  maintain  position, 
and  lost  their  patients.  The  supposition  that  the  shortening  of  the  limb 
is  sufficient  to  relax  the  contracted  muscles,  proved,  in  their  respective 
cases,  to  be  erroneous. 

II.  I  remove  with  great  care  and  accuracy  as  much  of  the  synovial 
membrane,  serous  slides  and  bursjc  (Bilroth)  as  are  extant  and  exposed 
to  air,  for  they  will  suppurate  and  materially  retard  union. 

At  this  juncture  the  debilitated  state  of  the  constitution  deserves  the 
closest  attention.     No  medication  will,  however,  be  of  service  as  long  as 
the  local  troubles  are  not  mitigated  by  a  proper  course  of  local  treat- 
'  ment. 

The  amelioration  of  the  articular  disease  is  the  most  direct  way  of 
relieving  constitutional  reaction.     Nevertheless,  quinine,  iron,  co'.5  liver 
oil  and  sedatives  may  be  needed  to  control  fever,   pro  note  luBmatosia, 
supply  an  easily  digested  nutriment,  and  secure  repose  and  immunity 
from  pain. 

In  morbus  coxariiis  the  principles  of  division  of  the  morbid  periods  rest 
on  a  diflferent  foundation,  and  accordingly  the  third  st;ige  of  that  disease 
is  determined  by  the  spontaneous  disruption  of  the  articulation  and  a 
peculiar  malposition  of  the  affected  member. 

It  is  of  course  necessary  to  ascertain  the  anatomical  and  clinica' 
character  of  the  existing  malady,  to  determine  the  plan  for  therapeutic 
action. 

If  the  inflammatory  character  of  the  disease  still  prevails,  the  appro- 
priate means  will  readily  suggest  themselves  from  preceding  remarks  ; 
and  as  readily  if  caries  has  ensued.  The  contracted  muscles  reqi  ire 
division  to  allow  the  reduction  of  the  existing  malposition.  Next,  the 
articulation  should  be  kept  at  rest  by  means  and  appliances  with  which 
we  have  already  become  acquainted  ;  irrespective  to  the  prevailing  state 


m 


i 


li 


i1 


4 


of  the  joint ;  being  equally  beneficial  in  arresting  articular  inflammation  a>; 
preventive  to  the  irritative  grating  of  carious  surfaces  upon  one  another. 

If  anchylosis  should  thus  ensue,  it  will  take  place  in  the  most  desirable 
and  useful  position  of  the  extremity. 

Locomotion  of  the  patient  renders  the  use  of  crutches  indispensible, 
the  weight  of  the  body  will  aggravate  the  local  trouble.  Only  when  the 
caput  femoris  shows  disposition  to  slide  up  and  backwards,  does  extension 
become  imperative.  My  portative  apparatus  (fig.  6)answcrs  the  indications. 

When,  however,  no  improvements  in  the  pathological  condition  of  the 
joint  follow  this  treatment,  when  caries  and  suppuration  continue,  and 
threaten  the  patient  with  hectic,  then  the  exsection  of  the  head  of  the 
femur  is  justifiable  and  appropriate. 

Fortunately  the  rational  and  successful  treatment  of  morbus  coxarius, 
lessens  the  exigency  of  that  operation,  and  to  this  fact  we  may  ascribe  the 
present  rarity  of  its  preformance. 

Notwithstanding  the  avowed  aversion  of  French  surgeons  to  this  oper- 
ation, it  cannot  be  denied  that  it  h:i'<  furnished  a  fair  statistic  of  success, 
and  that  it  has  saved  the  life  of  many  a  patient,  which  otherwise  would 
have  been  lost. 

Of  the  seventeen  partial  exsections  of  the  hip  joint  which  I  have  per- 
formed in  the  course  of  my  surgical  career,  nine  were  attended  by  re- 
covery and  two  are  still  under  treatment. 

The  limbs  have  been  shortened  from  one  to  three  inches.  f 

With  the  exception  of  one  case,  the  sclerotic  tissue  formed  between  the 
acetabulum  and  the  shaft  of  the  femur,  permitted  a  moderate  mobility, 
and  is  strong  enough  to  bear  the  superincumbent  weight  of  the  body. 

That  case  concerns  a  young  lady  upon  whom  T  operated  in  the  year  1S56 
when  she  was  nine  years  of  age.  Owing  to  monstrous  obesity,  the  inter- 
mediate substance  has  never  become  firm.  I  have  seen  this  patient  but 
lately,  she  has  grown  to  be  a  handsome  and  healthy  woman ;  and  I  have 
again  had  an  opportunity  of  examining  into  her  condition.  When  she 
stands  on  her  right  limb,  the  mere  weight  of  her  left  suffices  to  bring  it 
to  its  full  length.  But  if  she  rests  upon  the  latter,  the  intermediate  sub. 
stance  bends  outwards  and  allows  the  shaft  of  the  femur  to  come  in  con- 
tact with  the  acetabulum,  by  which  the  limb  is  three  inches  shortened. 
In  this  positon  she  can  bear  the  entire  weight  of  the  body  upon  the  af- 
fected side.  My  apparatus  gives  her  the  desired  support  for  locomotion, 
and  with  it  her  gait  is  easy  and  graceful. 

I  apprehend  that  some  of  the  exsections  which  I  have  performed,  have 
been  under  rather  unfavourable  circumstances,  and  yet  withal  the  conjoint 
result  is  anything  but  discouraging ;  some  of  my  patients  died  of  other 


G7 

diseases  (two  of  laryngeal  diphtheria,  and  one  of  cerebral  meningitis) 
evidently  connected  with  the  impoverished  state  of  their  respective 
nutrition. 

Though  I  am  not  a  great  admirer  of  exsection  of  the  hip  joint,  never- 
theless I  honestly  believe  that  its  performance  when  warranted  by  the 
anatomical  changes  of  the  joint,  bids  as  fair  a  chance  of  success  as  the 
exsection  of  any  other  joint.  It  is  scarcely  necessary  to  remove  carious 
portions  of  the  acetabulum  unless  very  accessible,  for  the  nutrition  of 
that  portion  of  the  pelvis  is  unimpaired,  and  inasmuch  as  it  remains  ac- 
cessible to  local  appliances,  it  becomes  soon  repaired. 

In  those  patients  who  died  after  the  operation,  I  invariably  found  the 
acetabulum  restored  to  its  integrity. 


1 


VI. 


TREATMENT  OF  THE  SEQUELAE  OF  JOINT 

DISEASES. 


The  most  judicious  and  diligent  treatment  sacceeds  but  rarely  in  re- 
storing the  affected  articulations  to  a  perfectly  normal  status.  There  re- 
mains generally  some  tenderness  of  the  articulation,  which  shows  itself 
after  a  liberal  use,  and  on  changes  of  the  weather.  Besides  a  certain 
stiffness  and  dryness  may  continue  a  long  time  after  the  disease  has  be- 
come completely  extinct. 

The  treatment  of  this  symptom  may  be  fulfilled  with  aromatic  lubri- 
cations, cold  and  warm  douche,  flannel  bandaging,  the  longer  use  of 
"  sole  baths,"  which  in  Germany  have  acquired  great  reputation  in 
these  troubles.  More  than  all,  passive  and  active  exercises  are  best  cal- 
culated to  give  permanent  relief.  Even  slight  malpositions  may  be 
gradually  overcome  in  this  way.  There  are  quacks  in  every  country  who 
acquire  reputation  and  lucre  from  the  treatment  of  these  articular  im- 
pediments, and  surgeons  may  learn  from  them  the  undeniable  benefit  of 
the  use  of  apparently  so  insignificant  remedies  as  lubricating  frictions 
and  passive  exercises.  I  have  myself  to  acknowledge  some  practical  in- 
formation from  this  rather  turbid  source.  Having  straightened  the  con- 
tracted knee  of  a  lady  patient,  and  repeatedly  moved  the  same  under 
chloroform  without  succeeding,  I  at  last  gave  it  up.  After  some  months 
I  again  met  her,  with  a  perfectly  flexible  and  useful  jc'nt,  and  learned 
that  a  female  quack  had  restored  her  extremity  to  usefulness  by  persis- 


68 


M 


■=?! 


tent  and  daily  lubrications  and  passive  motions.  In  the  beginning,  the 
treatment  had  been  very  painful  and  almost  unendurable  ;  but  gradually 
the  pain  had  subsided.  I  need  not  to  assure  you,  gentlemen,  that  this 
lesson  was  never  forgotten  by  me ;  and  I  am  anxious  to  impart  its  bene- 
fit to  you.  If  you  have  no  time  yourself,  I  would  advise  you  to  employ 
menial  hands,  but  do  not  give  quackery  a  pretence  to  superior  skill  and 
practical  efficiency. 

The  passive  motions  are  best  commenced  with  the  assistance  of 
chloroform,  which  will  enable  us  to  overcome  impediments,  without  any 
hazard  whatever  to  the  patient.  Tenderness  of  the  joint  may  follow, 
bit  will  subside  with  a  day  or  two  of  rest.  The  passive  motions  should 
then  be  renewed  with  or  without  chloroform,  as  the  case  demands,  and 
should  be  carried  on  until  the  desired  results  are  achieved.  The  patient 
may  greatly  assist  our  efforts  by  appropriate  movements. 

If,  however,  the  previous  treatment  has  been  inefficient  and  regardless 
of  conse'juences,  the  patient  will  present  more  aggravated  conditions. 
The  very  best  treatment  is  no  sure  protection  against  an  obliteration  of 
the  articular  cavltij ;  hnt  m'llposition  of  the  joint,  mnif  and  should  al- 
■ways  he 2»'evented. 

Anchylosis  forms,  then,  another  object  of  after  treatment.  Surgery  dis- 
criminates two  forms ;  the  false  or  fibrous,  and  the  true  or  bony,  to 
which  might  be  added  a  third,  by  bony  bands  or  osteophytes.  The  first 
consists  of  partial  or  total  connection  of  the  articular  faces  by  sclerotic 
tissue,  the  second  in  tlie  bony  interposition,  and  the  third  forms  a  partial 
osseous  involucrum  of  the  joint.  The  false  anchylosis  results  from 
synovitis,  both  primary  and  consecutive ;  the  true  from  penetrating 
wounds  and  caries  of  the  articular  faces ;  and  the  last  from  suppurative 
periostitis. 

There  is  always  more  or  less  mobility  in  false  anchylosis,  but  there  is 
no  vestige  when  osseous  material  forms  the  connecting  link.  When  mus- 
cular contractions  existed  previous  to  the  agglutination  of  the  articular 
faces,  the  mutual  anatomical  relations  of  the  latter  are  invariably  changed. 

The  treatment  of  anchylosis  has  always  been  a  cherished  object  of 
surgery  froa;  Hippocrates  down  to  the  present  time.  Success  is,  however, 
but  of  recent  date. 

Gradual  extension  for  the  purpose  of  overcoming  fibrous  anchylosis  is 
an  old  surgical  proceeding  and  has  from  time  to  time  found  advocates  in 
the  professional  ranks.  Mechanical  ingenuity  has  found  a  fruitful  field 
for  display  in  the  construction  of  all  sorts  of  instruments ;  the  latest 
method  imtroduced  is  that  by  pulley  and  weight. 

The  usefulness  of  gradual  extension  in  the  treatment  of  fibrous  anchy- 


M 


losis,  is  foi'  obvious  reasons  but  limited  and  condidcmaJ.  and  the  attempt 
to  substitute  the  same  for  hrisemcnt  force  is  a  failure. 

The  anatomical  conditions  resultinsi;  from  joint  disoasts  are  hut  ex- 
ceptionally amenable  to  that  method  :  it  is  tedious  at  best,  and  frequently 
so  painful  as  not  to  be  borne  by  many  patients.  It's  claimed  superiority  is, 
moreover,  anytliing  but  conclusive.  Nevertheless  we  meet  with  cases  in 
which  the  elastic  resistance  of  intra-articular  adhesions  and  of  the  capsu- 
lar ligament  can  be  but  overcome  by  gradual  and  persistent  extension, 
and  in  these  it  seems  to  be  the  only  remedy.  These  conditions  we  recog- 
nize only  after  unsuccessful  attempts  at  hrinament  forci,  and  the  latter 
has  therefore  to  precede. 

Such  cases  maybe  rare  and  constitute  but  a  small  fraction  in  statistics, 
but  they  do  exist,  notwithstanding  their  denial. 

I  possess  two  specimens  of  this  very  character,  in  my  collection,  both 
derived  by  amputation  of  the  thigh.  One  belongs  to  a  lady  who  had 
contracted  fibrous  anchylosis  of  the  knee  from  rheumatit;  synovitis,  aggra- 
vated by  contraction  of  the  hamstring  muscles.  Before  coming  under 
my  charge,  she  had  sufiered  hriscment  force  without  previous  division  of 
the  contracted  flexor  muscles.  Violent  reactive  inflammation  of  the 
joint  followed  the  forcible  extension,  and  the  latter  was  too  painful  to 
be  maintained.  The  integuments  .sloughed  at  the  internal  circumfer- 
ence of  the  articulation,  and  her  constitution  was  so  violently  shaken  tliat 
her  recovery  was  placed  in  jeopardy ;  and  when,  after  many  months  of 
severe  suffering,  she  had  regained  her  strength,  she  was  to  all  intents  and 
purposes  in  <i  worse  condition  tiian  bei'ore  the  operation.  Moreover,  the 
leg  was  in  so  high  graded  a  state  of  hyperaisthicsia,  that  si'e  could  not 
bear  the  slightest  touch,  and  the  thickened  epidermis  was  peeling  off  in 
large  patches.  Although  desirous  of  amputation,  I  deemed  it  my  duty 
to  try  once  more  hriscment  force.  Assuming  that  the  omission  of  myo- 
tomy was  the  cause  of  the  disastrous  failure  in  the  first  instance,  I  divi- 
ded the  contracted  hamstring  muscles  previous  to  the  operation  I  met 
no  difficulty  in  breaking  down  the  intra-articular  impediments,  but  I  ex- 
erted my  entire  physical  strength  in  vain  in  attempting  to  fully  extend 
the  leg.  T  succeeded,  perhaps,  to  an  angle  of  1G0°  but  could  not  keep 
the  leg  in  the  same.  It  would  jerk  back  in  an  instant  as  soon  as  I  re- 
linquished my  efforts.  • 

Applying  in  the  usual  manner,  longitudinal  adhesive  straps,  and  fast- 
ening to  the  same  a  weight  of  fifteen  pounds,  I  tried  gradual  extension 
over  a  pulley.  No  re-action  ensued.  The  limb  yielded  but  very  sparing- 
ly to  extension,  and  the  improvement  during  the  following  fortnight  was 
just  noticeable.    A  second  effort  was  then  made,  terminating  as  before.  I 


"l^ 


was  certfan  that  the  muscles  had  no  part  in  the  resistance,  having  been 
thoroughly  divided.  The  patient  lost  all  confidence  in  her  eventual  relief, 
aud  insisted  on  amputation,  which  I  dared  not  refuse ;  for  irrespective 
to  the  deformity,  the  hypcraesthaesia  alone  rendered  her  condition  in- 
sufferable. The  examination  of  the  specimen  revealed  the  fact  that  the 
resistance  was  exclusively  due  to  the  posterior  wall  of  the  capsular  liga- 
ment, which  was  greatly  thickened  and  pervaded  with  copious  elastic 
fibres.  Even  after  I  had  cleared  it  of  tendons,  lateral  and  crucial  liga- 
ments, it  was  impossible  to  straighten  the  joint. 

The  other  specimen  refers  to  a  little  girl  eight  years  of  age,  who  had 
two  years  previously  actjuired  an  aiTection  of  the  knee  joint  through  trau- 
matic injury.  When  I  took  charge  of  the  case  I  found  her  knee  joint  in 
an  angular  position,  and  its  mobility  greatly  impeded  by  intra-articular 
adhesions.  There  were  some  fistulous  openings  at  the  internal  circum- 
ference of  the  articiilation,  al  the  bottom  of  which  bare  bone  could  be 
felt  to  a  limited  exte;it. 

In  attempting  to  perf)rni  brisemcnt  force,  the  reisistance  of  the  ad- 
hesions was  very  great,  and  though  I  proceeded  with  great  care  and  pre- 
caution, I  had  the  misfortune  to  produce  diastasis  of  the  femoral  epiphy- 
sis. The  limb  was  again  placed  in  its  original  malposition  and  kept  at 
rest,  and  well  sustained  by  plaster  of  Paris  bandages.  No  trouble  at  all 
followed  the  unsuccessful  attempt,  and  the  epiphysis  was  in  due  time 
found  firmly  united  with  its  shaft.  Though  I  did  not  feel  inclined  to 
hazard  another  trial  of  the  same  kind,  but  was  prevailed  upon  by  the 
uncle  of  the  patient,  who  is  himself  an  esteemed  physician,  and  by  the 
family  at  Itirge.  i'^ou  may  well  suppose  that  I  was  very  timorous  in  the 
second  attempt,  and  that  I  used  no  undue  force.  In  fact  the  extension 
of  the  limb  was  effected  by  st'-aight  traction  and  without  using  the  re- 
spective bones  as  If  vers.  On  tiiis  occasion  I  succeeded  in  opening  the 
angle  considerably,  without  being  able  to  straighten  the  limb  completely. 
But,  as  in  the  former  case,  there  was  an  elastic  resistance  to  contend  with, 
which  reduced  the  angle  at  once  as  soon  as  the  tractions  were  slackened. 
Moreover  the  extension  of  the  limb  was  accomplished  at  the  expense  of  a 
shifting  of  the  tibia  backward  on  the  femur,  and  a  slight  bending  of  the 
tibia  and  femur.  There  was  no  separation  of  the  articular  faces.  Al- 
though I  had  again  divided  the  hamstring  muscles,  and  again  allowed 
the  limb  to  resume  its  old  malposition,  nevertheless  the  ensuing  re-action 
was  quite  formidable.  The  patient  being  of  a  very  delicate  and  nervous 
constitutir  ,  could  not  have  endured  without  succumbing  to  the  violence 
of  the  symptoms,  and  therefore  amputation  was  resorted  to  to  avert  the 
fatal  catastrophe.  Happily,  recovery  ensued  without  any  untoward  oc. 
currence. 


71 


In  this  specimen  the  resistance  was  due  to  the  strength  and  elasticity 
of  the  iutra-articuhir  fibrous  adhesions,  and  I  was  unable  to  overcc  3  it 
by  any  means  short  of  entire  demolition  of  tiie  specimen.  In  attempting 
to  straighten  the  same,  the  epiphyses  of  both  constituent  bones  were  pro- 
protionatcly  compressed  and  the  shafts  bent,  whilst  the  anatomicar  rela- 
tions of  the  joint  remained  unchanged. 

It  is  very  evident  that  from  tiiese  and  similar  causes,  the  extension 
per  force,  is  not  always  practicable,  and  there  remains,  consequently,  a  li- 
mited orthopaedic  field  for  the  employment  of  gradual  extension. 

Vv^hen  in  London,  I  saw  a  young  woman  at  the  Royal  Orthoprcdic 
Hospital,  who  had  been  successfully  relieved  by  gradual  extension,  from 
a  fearful  distortion,  caused  by  a  very  thick,  and  apparently  unyielding  cica- 
trix, the  result  of  an  extensive  burn.  Her  chin  had  been  literally  drawn 
down  and  fixed  to  the  chest.  She  was  then  still  under  treatment,  but 
her  head  stood  already  erect,  and  most  of  ifs  motions  were  free;  the  cica- 
trix was  soft  and  pliable.  This  startling  result  had  been  achieved  by 
persistent  gradual  extension  throughout  three  successive  years. 

The  anatomical  composition  of  scar  tissue  is  the  same  which  character- 
izes the  fibrous  impediments  of  my  cases,  and  if  the  former  can  yield  to 
persistent  extension,  the  latter  likewise  will. 

In  preferring  this  method  in  any  given  case,  I  should  advise  to  re- 
move all  and  every  muscular  resistance  by  previous  division.  There  are 
some  authors,  among  whom  Barwell  occupies  a  prominent  position, 
who  oppose,  for  several  reasons,  this  operation  as  unnecessary  and  objec- 
tionable. According  to  their  reasoning  the  contracted  muscles  are  in  a 
state  of  clonic  spasm,  which  will  yield  to  persistent  extension. 

I  have  already  exposed  the  fallacy  of  tr.is  opinion  in  another  place,  and 
proven  by  theory  and  practice  the  inefficiency  of  gradual  extension,  in 
as  fiir  as  muscular  contraction  is  concerned.  But  if  it  is  impossible  to 
extend  them  in  more  recent  cases  of  joint  disease,  it  is  surely  impractic- 
abie  in  protracted  cases,  and  after  the  muscular  tissue  has  been  displaced 
by  structural  elements  devoid  of  expansibility. 

From  my  experience,  gradual  extension  is  absolutely  dangerous,  being 
apt  to  produce  fearful  and  insufferable  pain,  and  reproduce  the  original 
disease  of  the  joint. 

I  am  indeed  astonished  at  the  self-assurance  with  which  JMr.  Barwell 
claims  invariable  success.  The  field  of  his  clinical  observation  must  in- 
deed have  been  very  limited  when  he  never  met  with  cases  in  which 
gradual  extension  gave  rise  to  serious  troubles.  All  his  arguments 
against  the  division  of  contracted  muscles  are,  moreover,  of  a  very  insigni- 
fict.nt  nature.     Mr.  Barwell  says  the  divided  tendons  of  muscles  do  not 


72 


i'ti 

h 


( im 


I 


readily  unite.  I  deny  this  assertion  as  entirely  unfounded ;  if  the  divi- 
sion is  carefully  performed  and  the  theca  of  the  tendon  respected,  it  will 
unite  readily  and  form  firm  and  reliable  connection.  My  experience  has 
been  rather  the  other  way,  and  therefore  I  have  been  occasionally  com- 
pelled to  re-divide  the  same  structures. 

Next,  it  is  asserted  that  the  divided  muscle  is  so  much  shortened  by 
the  operation  as  to  lose  entirely  its  physiological  office.  However,  how 
can  the  muscle  lose  a  function  which  it  does  not  possess  ?  The  division 
of  muscles  whicli  had  not  entirely  lost  their  physiological  expansibility, 
does  not  permanently  destroy  it ;  I  havj  had  plenty  of  proofs  to  that  ef- 
fect in  my  practice. 

The  fact  is  that  most  of  these  muscles  arc  worthless  before  and  after 
their  division,  beci.use  most  patients  content  themselves  with  a  straight 
and  useful  extremity,  though  the  mobility  of  the  interested  joint  may 
have  been  partially  or  totally  lost. 

The  inefficiency  of  gradual  extension  has  led  to  the  adoption  of  a  more 
efficacious  and  practicable  method  for  the  treatment  of  fibrous  anchylosis, 
known  as  forcible  extension  or  bruement  force. 

Some  twenty  years  ago,  Aniussat  called  the  attention  of  the  Royal 
Academy  of  Medicine  to  the  method  of  M.  Louvrier,  and  caused  a  com- 
mittee to  be  appointed  to  investigate  its  startling  results.  The  report 
thus  elicited  from  competent  surgical  judges,  presented,  that  up  to  that 
time  Louvrier  had  treated  twenty-three  cases  of  contractions  of  tlie  knee 
joint ;  that  he  employed  a  rather  clumsy  and  complicated  apparatus  by 
means  of  which  he  forcibly  broke  down  all  resistance  and  straightened 
the  respective  limbs ;  that  the  results  were  but  imperfect ;  that  no  good 
form  was  obtained  ;  that  a  few  had  been  straightened  perfectly  and  re- 
mained so  ;  that  in  some,  posterior  subluxation  of  the  tibia  had  been 
produced  and  that  three  patients  had  died  from  operative  shock,  puvulent 
infiltration  and  pyemia.  Louvrier  himself  admitted,  with  laudable  can- 
dour, the  short-comings  of  his  method. 

\\\  spite  of  the  enthusiasm  on  the  part  of  the  younger  members  of  the 
profession  for  the  new  method,  it  met  with  but  a  cold  reception  among 
the  conteniporaneous  surgeons  of  note.  But  a  low  therapeutical  estimate 
was  put  upon  it,  and  nt  best  it  was  pronounced  a  cruel  measure  worse 
than  the  trouble  it  was  designed  to  relieve.  Forgusson  and  Stromeyer 
were  its  most  cjtermined  --^'^oneuts  and  disposed  of  it  in  not  very  flatter- 
ing terms. 

If  I  do  not  mistake,  Dieffenbach  was  the  only  surgeon  of  distinction  who 
not  only  vindicf  ted  brisement  force  but  had  the  courage  to  adopt  it  against 
all  clamour.     He,  however,  modified  the  proceeding  by  substituting  the 


hand  for  the  surgical  rack  of  Louvrier,  and  included  tenotomy  and  myo- 
tomy as  preparatory  measures. 

In  a  comparatively  short  time  this  distinguished  surgeon  had  operated 
upon  200  patients,  and  reports  the  general  result  in  his  wo^k  on  operative 
surgery,  to  the  effect  that  he  lost  but  two  patients  from  suppuration  and 
pyaBmia ;  amputation  was  required  in  one ;  in  some  the  limb  was  improved 
to  a  moderate  degree,  in  others  anchylosis  became  re-established.  A  large 
proportion  of  the  patients  were  materially  benefited. 

Some  advancement  has  this  r^ethod  of  treatment  received  at  the  hands 
of  Professor  Bernhard  Langrabeck,  of  Berlin,  but  it  should  be  remem- 
bered that  he  had  a  most  j  owerful  aid  in  chloroform.  In  his  inaugural 
dissertation,  on  entering  upon  his  professorship,*  he  pronounces  gradual 
extension  ineffective ;  the  division  of  the  contracted  muscles,  as  perform- 
ed by  Dieffenbach,  as  superfluous,  and  even  dangerous,  by  inviting  the 
entrance  of  air  and  thus  giving  rise  to  suppuration.  Louvrier's  method 
is,  according  to  him,  too  uncertain,  and  its  results  removed  from  the  con- 
trol of  the  surgeon.  The  technicism  of  Langenbeck  conforms,  in  most 
points,  with  those  of  Dieffenbach.  The  results  which  Langenbeck  at- 
tained up  to  1853,  are  compiled  in  the  inauguial  dissertation  of  Philipp 
Frank.f 

In  carefully  analyzing  the  results  of  Louvrier,  Dieffenbach,  and  Lan- 
genbeck, and  in  comparing  them  with  each  other,  it  cannot  be  denied 
that  Dieffenbach's  were  superior  to  Louvrier,  and  Langenbeck's  better 
than  his  predecessors.  But  all  of  them  are  certainly  imperfect,  and  by 
no  means  satisfactory.  Louvrier  caused,  in  three  cases,  considerable  in- 
juries to  the  knee-joint,  and  consequently  lost  them.  Of  what  nature 
these  injuries  wore  I  have  not  learned,  nor  the  reason  why  they  hap- 
pened in  three  cases,  and  not  in  the  remainder.  Very  likely  that  they 
were  cases  of  true  anchylosis,  and  that  be  fractured  the  bones,  or  caused 
diastasis  of  the  epiphysis,  or  tore  vessels  or  nerves.  The  subluxation  of 
the  tibia,  in  almost  all  the  cases  of  Louvrier,  must  have  been  a  great  de- 
trimcn*  'o  the  final  result  of  his  treatment.  For,  in  the  first  place,  the 
posterior  projection  of  the  tibia  must  have,  by  necessity,  compressed  the 
popliteal  nerves  and  vessels,  thus  materially  interfering  with  the  circula- 
tion and  innervation  oi:  the  leg.  Again,  the  gastrocnemius  was  evidently 
put  on  the  stretch,  and  the  heel  prevouted  from  reaching  the  ground. 


♦Commentatio  de  contractum  et  ancliylo3i  genu  uova  metbodus  violcatbi  ex- 
tensionif    ne  curaudis.     Boroliui,  1850.  ■        '  ^        ' 

t  De  contractura  et  atichylosi  articulatiouis  genu  et  cora?;  Beiolini,  1552. 


i!,:^-ii.m 


74 


Moreover,  the  contracted  flexor  muscles  were  so  much  irritated  as  to 
cause  serious  subsequent  troubles.  DieflFenbach's  method  was,  therefore, 
a*material  improvement.  In  using  manual  force  alone,  he  protected 
himself  against  the  error  of  meddling  with  cases  of  true  anchylosis,  not 
amenable  to  brisement  force,  and  by  dividing  the  contracted  muscles  he  re- 
lieved the  patient  from  the  serious  consequences  appertaining  to  undue  ex- 
tension. Lastly,  in  breaking  the  anchylosis  up,  by  alternate  flexion  and  ex- 
tension, he  obviated  subluxations  of  the  tibia.  The  real  merits  of  Louvrier 
or  Dieffienbach  for  the  advancement  of  this  province  of  orthopaedic  surgery 
are,  in  my  humble  judgment,  obviously  greater  than  those  of  Langenbeck. 
The  method  of  the  latter  is  essentially  that  of  Dieffenbach  deprived  of  the 
benefit  of  tenotomy,  but  favoured  by  chloroform. 

I  have  the  most  unreserved  appreciation  of  the  great  talents  and  dili- 
gence of  Langenbeck,  but  I  appreciate  truth  and  clinical  facts  still  higher. 
About  600  cases  of  aiTeotion,  contraction,  and  anchylosis  of  the  knee-joint 
have  given  me  ample  opportunity  for  most  thorough  clinical  observations, 
and  entitles  me  to  a  participation  in  the  settlement  of  the  important  ques- 
tion which  is  still  being  discussed  by  the  highest  scientific  tribunals  of 
Europe,  before  which  Langenbeck  maintains  his  former  position. 

On  the  feasibility  of  brisement  ford  we  all  agree.  Its  super ioiity 
over  progressive  extension  can  no  more  be  questioned,  and  its  former  op- 
ponents have  been  effectually  silenced  by  the  overwhelming  results  of 
that  practice.  It  has  also  been  clearly  demonstrated  that  the  hand  is  a 
better  mechanical  adjuster  than  the  lever  and  the  screw.  But  for  the  in- 
troduction of  anaesthetics,  more  especially  of  chloroform,  the  operation 
would  have  been  of  little  practical  value.  The  pain  attending  it  is 
severe  enough  to  terrify  the  boldest  patient  and  surgeon.  The  subse- 
quent suff'erings  it  entails,  and  the  uncertainty  of  its  success,  would  have 
driven  it  again  into  oblivion.  Chloroform  and  tenotomy  assure  the 
future  of  brisement  force.  The  former  renders  it  perfectly  painless,  the 
latter  protects  against  consecutive  effects,  which  are  worse  than  anchy- 
losis and  the  contraction  of  the  knee-joint  together.  I  do  not  dispute 
that  in  some  instances,  simple  extension  will  suffice  to  overcome,  perma- 
nently, a  moderate  reflex  contraction.  Further,  I  have  observed  that  a 
weight  of  a  few  pounds  fastened  to  the  extremity  for  a  few  days  will 
have  the  same  effect.  But  a  high  degree  of  muscular  contraction  can  be 
subdued  by  division  alone.  The  name  of  Langenbeck  was  sufficient  in- 
ducement for  to  follbw  his  directions.. 

I  have  tried  his  method  in  quite  a  numbjr  of  cases,  and  succeeded,  in 
most  of  them,  in  extending  the  extremity,  but  as  soon  as  the  anassthesia 


Ml  'W 


75 


subsided,  the  muscles  commfcaced  contracting  again,  or,  if  prevented 
therefrom  by  mechanical  restraint,  an  intense  suffering  ensued.  There 
are  but  few  maladies  that  cause  so  intense  agony,  and  prostrate  the 
constitution  in  so  short  a  time,  as  the  persistent  extension*of  contracted 
muscles.  I  remember,  among  several  cases,  particularly  one|of  a  little  boy^ 
who  was  brought  on  from  Montgomery,  Alabama,  with  a  contraction  of 
the  knee-joint.  The  original  disease,  synovitis,  had  subsided  two  years  be- 
fore. The  joint  was  quite  well,  and  there  was  no  pain  felt  cither  on 
motion  or  pressure.  Moreover,  the  mobility  of  the  joint  was  not 
materially  disturbed  beyond  the  impediment  of  the  contracted  flexors. 
Under  chloroform  only  the  biceps  muscle  felt  tense,  and  I  divided  it.  I 
then  easily  succeeded  in  extending  the  leg,  and  in  securing  its  position 
in  a  straight  splint.  The  anaesthesia  had  scarcely  passed  off,  when  the 
patient  began  eying  loudly,  and  very  soon  the  articulation  became  ten- 
der and  distended.  Inflammatory  fever  set  in,  with  a  pulse  of  150. 
The  strongest  opiates,  the  most  active  and  persistent  general  and  local 
antiphlogistics  made  no  impression  whatsoever.  The  paroxysmal  pains 
suggested  to  my  mind  their  specific  character.  On  relieving  the  limb 
from  its  restraint,  it  immediately  bent.  This  was  another  indication  ia 
the  same  direction,  and  yet  the  tension  of  the  remaining  undivided  flexor 
muscles  was  so  trifling  as  scarcely  to  deserve  notice.  On  the  sixth  day 
after  the  operation,  the  joint  was  greatly  distended  and  fluctuating,  with- 
out the  slightest  sign  of  amendment.  At  that  juncture  I  again  placed 
the  patient  under  chloroform,  when,  again,  all  muscular  tension  vanished^ 
and  I  had  to  wait  for  the  subsidence  of  anesthesia  in  order  to  mark  the 
tendons  to  be  divided.  What  sedatives  and  the  whole  antiphlogistic 
apparatus  failed  to  effect,  tenotomy  did.  Rest  immediately  ensued  there- 
from. From  that  moment  improvement  commenced,  and  eventuated  in 
perfect  recovery.  I  could  adduce  several  instances  of  the  same  striking 
and  conclusive  nature.  But  one  will  suffice  to  illustrate  the  importance 
of  tenotomy  in  the  treatment  of  the  deformity  under  consideration.  I 
shall  now  proceed  to  delineate  the  plan  which  I  have  adopted,  and  whi^h 
I  have  reason  to  believe  is  the  mildest,  the  safest,  and  certainly  the  most 
effective.  First,  be  certain  in  the  diagnosis.  Fibrous  anchylosis  may  be 
easily  recognized,  for  there  always  remains  a  moderate  degree  of  mobility 
at  the  joint ;  even  osteophytes  are  not  incompatible  with  mobility,  more 
especially  when  they  arise  from  one  bone,  and  do  not  firmly  connect  with 
the  other.  But  if  both  bones  are  united  by  osteophytes,  there  is  noth- 
ing left  of  mobility,  and  in  as  far  as  the  latter  is  concerned,  there  is  no 
symptomatic  difference  bctwocn  a  true  anchylosis  and  that  caused  by 


;  "  -  -76. 

osteophytes.  The  previous  history  of  the  case  alone  can  glva  you  a  duo 
as  to  the  nature  of  the  anchylosis.  From  the  preceding  remarks  you 
may  be  led  tc  expect  osteophytes  from  previous  periostitis,  and  true  bony 
union  from  a  more  structural  affection  of  the  joint  itself.  Supposing, 
then,  that  we  had  cither  a  fibrous  or  an  osteophy  tic  anchylosis,  with 
marked  contractions  of  the  flexor  muscles,  I  would  suggest,  first  of  all, 
to  divide  all  the  contracted  muscles.  It  will  be  better  to  do  this  six  or 
eight  daysprevious'to  the  performance  of  the  hrisemcnt  forcL  By  that  time 
the  wounds  have  firmly  closed.  No  air  can  enter  and  give  rise  to  sup- 
puration, and  you  obviate  at  least  one  of  the  objections  raised  by  the 
opponents  of  tenotomy.  It  is,  of  course,  indifferent  whether  you  use 
chloroform  on  that  occasion,  since  but  little  pain  accrues  from  the  opera- 
tion. Nor  do  I  deem  it  necessary  to  give  you  special  advice  as  to  the 
flexor  muscles  of  the  leg,  since  by  extension  you  can  raise  them  from  the 
adjacent  parts,  and  divide  them  successively  as  they  present  themselves. 
The  division  of  the  tendon  of  the  biceps  deserves  special  mention.  The 
external  popliteal  or  peroneal  nerve  is  in  such  close  approximation  to 
the  internal  margin  of  the  tendon  as  to  be  easily  cut  through.  If  this 
be  the  case,  paralysis  of  th«  abductor  muscles  of  the  foot  and  talipes 
varus  would  inavitably  follow.  In  order  to  avoid  this  nerve,  you  have 
to  divide  the  tendon  either  from  outside  by  dead  pressure  with  a  teno- 
tome not  too  sharp,  or  by  inserting  it  close  to  the  inner  margin  of  the 
tendon,  and  give  the  edge  an  outward  direction.  A^'ith  all  precaution 
imaginable,  I  have  nevertheless  met  with  this  accident  in  four  cases.  Yet 
I  am  happy  to  say  that  the  paralysis  arising  from  the  inadvertant 
division  of  the  nervus  peronseus,  did  not  exceed  six  months,  the  nerve 
having  probably  re-united,  and  thus  re-established  its  full  innervation. 

About  eighteen  months  ago,  I  took  charge  of  a  young  man,  who  had 
sustained  a  serious  accident  ;  his  right  knee-joint  having  been  opened  at 
its  outer  aspect  by  a  large  lacerated  wound.  The  tendon  of  the  biceps 
as  well  as  the  peronajus  nerve  were  demolished  for  about  an  inch.  The 
patient  has  never  recovered  the  action  of  that  nerve. 

But  oven  if  there  be  no  trace  of  mobility  in  the  joint,  as  in  complete 
osteoyhytes,  tenotomy  should  precede  hrisement  ford  for  reasons  requir- 
ing no  further  explanation, 

In  order  to  perform  Iriscmcnt  font  the  patient  should  be  fully  under 
the  influence  of  chloroform.  He  should  be  placed  on  his  face,  but  at  the 
same  time  due  attention  paid  to  respiration,  for  at  tliat  degree  of  anaes- 
thesia, respiration  is  very  feeble  and  in  the  main  diaphragmatic.  The 
slightest  impediment  may  entirely  arrest  it.    As  soon  as  the  patient  is  thus 


■■     ^  77    ;  .   . 

prepared,  you  have  the  thigh  properly  fixed  by  an  assistant,  and  then 
taking  hold  of  the  leg,  bend  it  with  a  sudden  jerk,  and  then  extend  it  ; 
and  so  continue  to  alternate  between  flexion  and  extension,  until  the  ar- 
ticulation is  quite  free. 

If  there  be  any  rotation  of  the  tibia,  it  will  be  advisable  to  amend  that 
position  by  re-twisting  it  in  the  opposite  direction.  This  done,  bandage 
the  extremity  carefully  with  a  roller,  surround  the  knee-joint  with  strips 
of  stout  adhesive  plaster,  and  fasten  either  the  extremity  in  a  straight  iron 
splint,  such  as  I  have  before  shown,  or  adjust  the  extension  with  the  pul- 
ley and  weight,  as  before  described.  In  order  to  correct  the  lateral  posi- 
tion of  the  limb.  Professor  Robert  places  side  cushions  inside  of  the  splints 
before  fastening  the  extremity. 

By  this  plan  I  have  obtained  mo^t  satisfactory  results,  and  have  never 
had  any  trouble  in  producing  a  speedy  and  steady  recovery  of  numerous 
patients.  It  was  never  followed  by  inflammation  or  neuralgia  which  other 
surgeons  have  complanicd  of;  nor  did  the  contraction  return,  provided 
all  the  contracted  muscles  had  been  successfully  divided.  If  any  of  those 
symptoms  should  set  in,  rest  assured  that  the  tenotomy  is  not  complete. 
The  earlier  you  perfect  it  the  better  it  is  for  your  patient.  It  is  need- 
less to  contend  against  them  by  antiphlogistics  and  sedatives  ;  you  will 
effect  nothing.     Tenotomy  is  the  only  remedy. 

Brisement  force  is  both  in  appearance  and  reality  a  powerful  remedy. 
It  overcomes,  by  main  force,  all  resistance  :  it  ruptures  the  fibrous  adhe- 
sions of  the  joint  and  unyielding  tissues,  and  can  certainly  do  great  mis- 
chief if  indiscreetly  performed.  But  in  using  the  necessary  precautions 
with  physical  power,  nothing  is  to  be  apprehended  therefrom.  In  the 
large  number  of  my  cases  I  have  had  but  four  accidents  :  one  of  them  was 
inevitable,  and  certainly  could  not  be  foreseen.  The  case  refers  to 
a  vouth  of  about  sixteen  years.  He  was  tall,  slender,  and  evident- 
ly of  feeble  constitution.  Having  been  employed  in  a  manufactory  in 
which  he  had  to  tread  a  wheel,  he  had  thus  acquired  an  inflammation  of 
his  knee-joint,  which  terminated  in  a  deformity.  His  leg  was  bunt  at  an 
angle  of  105°,  (Fig.  13),  but  permitted  mobility  within  an  angle  of  30° 
beyond  which  there  was  resistance  on  the  part  of  the  contracted  biceps 
and  other  articular  impediments.  The  patella  was  moderately  moveable. 
After  having  divided  the  tendon  of  the  biceps,  I  increased  the  flexion  of 
the  limb  by  a  cciparativcly  gentle  effort,  when,  to  my  surprise,  the  resist- 
ance suddenly  yielded. 

A  few  days  afterward  a  slough  appeared  in  the  popliteal  space,  and  the 
suppuration  became  so  profuse  as  to  render  ami.ututiou  imperative.     It 


ll- 


fi:  !■' 


ft  \ 


i ' 


\      .  .  78       .    ' 

was  then  found  that  the  epiphysis  of  the  femur  had  yielded,  whereas  the 
articular  adhesions  had  remained  unbroken.  (Fig.  14.)  The  dispropor- 
tionate strength  of  the  articular  adhesion,  over  the  union  between  the 
lower  extremity  of  the  femur  to  its  shaft,  was  the  proximate  cause  of  the 


(Fig.  13,) 

accident,  and  certainly  could  not  have  been  anticipated.  A  large  propor- 
tion of  my  patients  have  been  children  in  whom  the  same  condition  of  the 
femur  existed,  but  with  the  exception  of  a  few  cases,  I  have  met  with  no 
accident  whatever.  In  reference  to  the  case  just  related,  I  candidly  con- 
fess that  I  had  not  the  remotest  idea  that  such  an  accident  would  hap- 
pen at  the  age  of  the  patient,  nor  did  I  or  any  of  my  able  assistants  rea- 
lize its  occurrence.  It  was  in  fact  the  first  mishap  of  this  kind,  though 
it  has  not  been  the  last.  The  next  case  happened  with  a  lad  from  In. 
diana,  aged  17  years.  His  appearance  was  equally  delicate,  but  more  from 
rapid  growth  than  any  other  cause,  for  the  affection  of  his  knee-joint  had 


(Fig.  14.) 
subsided    some  years   previously.     I  performed  the  operation  at   the 
office  of  my  esteemed  friend  Dr.  Gaston  at  Indianapoli?,  av     n  the  prcsenco 
of  the  prominent  practitioners  of  that  city.     They  all  can  bear  witness 


lk:i 


m 


that  I  proceeded  with  great  care  and  precaution,  and  employed  no  undue 
violence. 

Nevertheless  a  diastasis  of  the  lower  epiphysis  of  the  femur  took  place, 
but  no  serious  consequences  followed,  beyond  the  delay  of  treatment,  which 
has  since  been  resumed.  "^ 

The  other  two  accidents  of  this  description  happened  with  children ; 
one  of  the  cases  I  have  already  adverted  to. 

These  accidents  are  indeed  of  no  great  consequence,  provided  they  are 
promptly  recognized  and  attended  to.  The  limb  must  be  brought  back 
into  the  former  position,  and  this  position  must  be  secured  by  bandages 
impregnated  with  plaster  of  paris;  in  six  or  eight  weeks  the  union  is  per- 
fect, and  the  treatment  may  then  be  renewed  without  further  hazard. 

It  seems  to  me  that  these  accidents  are  likely  to  happen  in  cases  where 
the  intra-articular  adhesions  are  rather  tough,  and  the  connections  between 
the  epiphy.s'  and  shaft  of  the  femur  somewhat  infirm.  The  latter  may 
be  expected  in  debilitated  and  overgrown  individuals,  an  J,  in  such,  more 
than  usual  precaution  is  needed  to  obviate  mishaps  of  this  description. 

If  we  consider  the  small  proportion  of  accidents  connected  ••  ith  brisc- 
ment  force,  and  the  large  number  of  operations  I  have  successfully  per- 
formed, they  scarcely  command  our  notice.  But  even  this  insignificant 
number  of  accidents  may  bo  reduced  by  still  greater  precaution,  and 
during  the  last  two  years  I  have  successfully  avoided  them  entirely,  and 
hope  to  do  so  for  the  future.  Whenever  I  have  reason  to  suspect  infirm 
epiphyseal  connections,  I  do  not  attempt  to  break  up  at  once  the  intra- 
articular impediments,  but  do  so  in  three  or  four  different  times  and  se- 
cure each  time  the  gain  by  appropriate  mechanical  appliances.  The  safest 
Wcv,  however,  to  break  up  adhesions  of  this  description  is  by  extension  and 
not  by  flexion,  as  I  have  before  advised.  The  latter  is  more  efiicacious 
but  more  dangerous  in  producing  diastasis. 

In  protracted  cases  of  false  anchylosis,  we  are  likewise  necessitated  to  re- 
peat the  forcible  extension  several  times  before  succeeding  in  giving  the 
extremity  the  full  benefit  of  a  straight  position,  and  we  may  succeed  at  a 
third  or  fourth  repetition  when  the  first  attempt  proved  very  inauspicious. 
This  is  especially  the  case  when  peri-articular  scar-tissue  complicates  the 
mechanical  diflSculty. 

After  the  brisement  forcd  has  been  performed,  the  extremity  should  be 
firmly  surrounded  by  a  well  applied  flannel  bandage,  with  ascending  tours, 
from  the  periphery  towards  the  interested  joint,  and  the  latter  with 
tightly  applied  strips  of  adhesive  plaster  spread  on  Canton  flannel,  over 
which  the  flannel  bandage  is  continued  to  the  body. 

The  extremity  is  then  placed  in  a  well  adapted  and  well  padded  iron 


'M 


i 


ll.t    I! 


80 

splint, .  and  thus  secured,  kept  at  rest  for  several  weeks,  until  the  last 
vestige  of  soreness  of  the  joint  has  disappeared. 

When  the  patient  is  perfectly  free  from  pain  or  other  symptoms,  he 
may  be  permitted  to  leave  his  bed,  and  walk,  but  even  then  the  limb 
should  be  supported  by  the  same  instrument  which  I  have  recommended 
for  the  after  treatment  of  inflammation  of  the  knee-joint.  (Vide  Figs. 
11—12.) 

Most  patients  content  themselves  with  a  straight,  useful  and  stiff  knee- 
joint.  But  very  few  insist  upon  the  re-establishment  ofmotion.  In  this 
case  all  those  measures  have  to  be  adopted  which  I  have  detailed  under 
the  treatment  of  stiff-joints.  To  realize  a  full  share  of  mobility  under 
these  circumstances  is  a  therapeutic  object  of  considerable  difficulty, 
and  should  not  be  entertained  without  due  deliberation.  The  number  of 
cases  in  which  I  have  succeeded  in  re-establishing  motion  is  very  small, 
and  in  two  only  perfect.  If  we  consider  that  in  most  of  these  cases  the 
articular  cartilages  and  the  synovial  lining  are  destroyed,  and  that  the 
intra -articular  fibrous  tissue  passes  from  bone  to  bone,  and  from  wall  to 
wall,  we  should  not  be  surprised  when  success  attends  but  rarely  these 
efforts.  Moreover,  the  intra-articular  fibrous  tissue  again  rapidly  unites 
with  tl:e  same  articular  surface  from  which  it  has  been  torn,  and  this  is 
an  additional  difficulty  in  the  re-establishment  of  free  motion. 

When  osteophytes  unite  the  bones  between  which  the  joint  is  formed, 
there  is  of  course  no  mobility,  and  the  firmness  of  the  joint  simulates  that 
of  true  bony  union,  although  the  previous  history  of  the  case  may  sug- 
gest the  character  of  the  abnormal  connection.  The  hrisement  forc6  is 
after  all  the  only  safe  diagnostic  test.  Fortunately  the  osteophytes 
are  not  true  bony  structure,  and  possess  neither  its  elasticity  nor  its  firm- 
ness. These  bony  splints  arc  rather  fragile,  and  break  readily  with  a 
crackling  sound  as  if  true  bone  was  giving  way. 

The  presence  of  osteophytes  does  not  in  any  way  interfere  with  the 
hnsement  ford  and  its  ulterior  results,  the  after  ti'eatment,  nor  is  it 
materially  affected  by  them. 

In  extensive  and  complete  osseous  union  of  the  knee-joint,  hrisement 
forci  is  of  course  ineffective.  Rhea  Barton's  operation  alone  is  calculated 
to  meet  the  emergency.  Although  originally  proposed  for  thorelief  of  an- 
chylosis of  the  hip -joint,  its  author  conceived  the  praccicability  of  the  opera- 
tion in  the  same  morbid  condition  of  the  knee-joint.  In  1835,  he,  for 
the  first  time,  performed  the  exsection  of  a  wedge-formed  piece  of  bone 
from  the  knee,  and  the  result  attained  was  highly  satisfactory.  The  wound 
closed  in  two  months,  and  in  five  and  a  half  months  the  patient  resumed 
his  avocation  as  a  practising  physician.  - 


t 


•r  i 


81 


I 


The  second  operation  of  this  kind  was  resorted  to  by  Prof.  Gibson,  of 
Philadelphia,  and  likewise  terminated  favourably,  the  patient  being  capa- 
ble of  walking,  without  crutches,  five  months  after. 

The  third  operation  Dr.  Gordon  Buck  successfully  Tierformed  at  the 
New  York  City  Hospital,  in  1844.  The  patient  subsequently  sustained 
a  fall  from  a  ladder  and  fractured  the  new  union ;  recovery  ensued  with- 
out any  untoward  accident. 

Since  then  the  same  operation  has  been  repeated  by  Mutter,  Bruns, 
(Tubingen,)  Heuser,  B,  Langenbeck,  Reid,  Robert,  Post,  (New  York,) 
and  others.  As  far  as  I  have  ascertained,  but  two  cases  proved  fatal 
(Bruns  and  Post;)  the  balance  recovered  with  useful  extremities.  The 
technicalities  of  Barton's  proceedure  may  be  found  in  every  work  on  opera- 
tive surgery. 

The  late  Prof.  Brainard,  of  Rush  College,  has,  some  years  ago,  sug- 
gested weakening  the  inter-articular  substance  by  drilling  it  in  various 
directions  through  a  smali  wound,  and  then  to  fracture  the  rest.  How 
many  operations  have  been  made  according  to  this  plan,  I  do  not  know, 
but  its  application  signally  failed  in  a  case  of  one  of  our  most  accomplish- 
ed surgeons,  (Prof.  Gross.)  and  a  chisel  had  to  be  resorted  to,  which  was 
driven  through  the  bony  connection. 

A  similar  proceeding  had  been  proposed  by  Prof  Shuh,  of  Vienna,  as 
early  as  1853,  but  did  not  meet  with  the  approval  of  German  surgeons. 

Whether  the  recently  introduced  so-called  osteoplastic  operation  of  B. 
Langenbeck  has  been  attempted  in  true  anchylosis  of  the  knee-joint,  I 
am  equally  ignorant,  but  apprehend  that  a  simple  separation  of  the  arti- 
cular faces  by  drill  or  saw  will  scarcely  sufl&ce  to  give  a  good  form  to  the 
extremity,  the  new  bony  substance  being  an  impediment ;  and,  therefore, 
I  would  prefer,  of  all  the  methods  suggested,  that  of  Rhea  Barton,  which 
has  proven  itself  both  effective  and  comparatively  harmless. 

The  indications  for  and  the  technical  execution  of  brisementforc^  are 
in  most  others  joints  the  same  as  at  the  knee-joint.  But  in  reference  to 
the  hip-joint  the  operation  is  subject  to  some  modification,  with  which 
I  shall  now  occupy  your  attention. 

Before  entering  upon  the  practical  consideration  of  the  subject,  a  short 
recapitulation  of  the  anatomical  condition  of  the  joint,  left  by  hip  disease, 
will  not  be  out  of  place.  Like  the  knee-joint,  this  articulation  presents 
the  three  forms  of  anchylosis.  Of  these  the  true  or  bony  anchylosis  is 
certainly  of  very  rare  occurrence  judging  from  the  few  specimens  of  this 
character  which  can  be  found  in  the  most  complete  collections  of  morbid 
anatomy.  I  do  not  think  that  I  have  scan  more  than  two  cases  during 
a  practice  of  nearly  thirty  years  duration.     Osteophytes  are  often  met 


82 


with  in  the  neighbourhood  of  the  hip  joint  recovered  from  morbus  cox- 
arius.     Fibrous  anchylosis  is  unquestionably  the  most  common  result  of 
that  disease,  and  we  find  it  generally  complicated  with  malposition  of  the 
thigh,  arising  from  muscular  contractions. 

I  have  had  repeated  opportunities  of  thoroughly  examining  the  anatomi- 
cal status  of  joints  thus  changed.  In  the  first  place  I  have  found  the  ace- 
tabulum enlarged  in  a  posterior  and  superior  direction,  giving  it  almost 
the  shape  of  a  figure  eight ;  the  new  accession  being  the  smaller  part. 
The  cartilaginous  covering  of  the  acetabulum  proper  had  almost  entirely 
vanished,  and  upon  the  accessory  portion  none  whatever  could  be  detected. 
In  some  instances  the  femur  was  riding  on  the  remnant  of  the  acetabular 
margin  separating  the  two  articular  segments,  and  for  this  purpose  had  a 
corresponding  groove  which  gave  it  an  accurate  fit. 

Of  the  femur,  the  head  had  been  entirely  lost  in  every  single  instance, 
and  the  neck  more  or  less  shortened. 

The  intra-articular  fibrous  adhesions  fastened  the  end  of  the  femur  to 
the  articular  surface  of  the  pelvis,  permitting  a  slight  degree  of  mobility. 
The  capsular  ligament  was  more  or  less  comprised  and  identified  with  the 
intra-articular  fibrous  structure,  and  could  only  in  one  case,  and  to  a  slight 
extent,  be  separated  therefrom. 

In  two  instances  fibrous  bands  obviously  of  a  neoplastic  character  strength- 
ened the  connection  of  the  femur  with  the  pelvis.  The  osteophytes  arose 
from  the  neighbourhood  of  the  acetabulum,  were  short  and  thick,  forming 
no  organic  connection  with  the  femur  and  would  have  ofiered  no  impedi- 
ment to  the  brisement  force. 

From  this  short  sketch  we  may  arrive  at  an  approximate  estimate  of  the 
prevailing  anatomico-pathological  conditions  which  hrisement  force  has 
to  contend  with. 

Buehring  was  the  first  who  extended  the  usefulness  of  hrisement  force 
to  the  hip  joint,  and  made  strenuous  efforts  to  correct  the  cO'  existing  de- 
formities. The  means  employed  by  him  were,  however,  so  defective  that 
but  imperfect  results  were  attained.  He  already  adverts  to  several  cases 
of  failure  and  disaster  ;  in  one  he  reproduced  the  original  disease  to  which 
the  little  patient  eventually  fell  a  victim.  And  I  have  to  place  an  in- 
stance on  record,  in  which  by  a  fall,  hrisementforcd  was  effected  and  sub- 
sequently followed  by  the  return  of  the  disease,  terminating  fatally.  The 
case  happened  with  a  lad  of  Swedish  extraction,  about  sixteen  years  of 
age.  The  original  disease  had  taken  its  course  through  several  years-, 
terminating  in  fibrous  anchylosis  of  the  joint  and  malposition  of  the  fe- 
mur, when  the  patient  was  about  ten  years  old.  Aside  from  the  existing 
impediment  to  locomotion,  he  had  not  been  troubled  for  six  years,  when 


83  -  '  ' 

he  fell  down  stairs  and  thus  forcibly  broke  the  existing  adhesions.  Violent 
suppuration  followed  the  accident,  and  destroyed  life  by  pyaemia.  Having 
secured  the  specimen  (Fig.  15),  I  had  the  rare  opportunity  of  satisfying 


(Fig.  15.) 

my  curiosity  in  a  pathological  point  of  view.  It  is  astonishing  to  me  how 
little  destruction  has  been  effected  by  the  late  suppuration.  All  the  ad- 
hesions have  been  of  course  carried  off,  and  the  bony  surfaces  in  contact 
with  each  other  are  osteoporotic,  which  is  probably  the  normal  condition 
in  connection  with  the  formation  of  fibrous  adhesions.  The  caput  femoris 
is  of  course  destroyed  by  the  original  disease,  but  the  neck  has  suffered 
no  changes  by  suppuration  since  its  articulating  surface  accurately  fits  in 
the  socket. 

I  have  mentioned  these  two  cases  for  the  purpose  of  showing  that 
brisement  forcd  of  the  anchylosed  hip  joint  is  a  proceeding  not  altogether 
devoid  of  danger.  Nevertheless  it  is  a  legitimate  operation  if  performed 
with  due  precaution,  but  the  most  brilliant  results  cannot  compare  with 
those  attainable  at  the  knee  and  elbow  joints. 

The  previous  division  of  the  contracted  muscles  is  to  be  insisted  upon. 
Myotomy  is  not  only  harmless  and  indispensable  to  a  satisfactory  result, 
it  lends  also  protection  against  the  recurrence  of  the  previous  morbus 
coxarius;  and  I  feel  persuaded  that  Buehring  would  have  had  better 
chances  to  save  his  patient  had  he  not  omitted  that  initiatory  operation. 
A  few  days  after  the  operation  we  may  then  proceed  to  loosen  the  joint. 
The  patient  is  to  be  placed  upon  the  table  in  the  recumbent  posture,  and 
when  under  the  full  influence  of  chloroform  his  pelvis  is  held  by  an 
assistant  grasping  both  sides,  with  the  thumbs  upon  the  anterior  superior 
pinous  process  of  the  ilium,  whilst  the  operator  presses  firmly  his  foot 
against  the  corresponding  tuber  ischii.     Thus  prepared,  he  takes  hold  of 


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the  affected  extremity,  and  with  a  firra,  steady,  but  gentle  traction,  extends 
and  abducts  the  limb.  Gentle  motions  and  rotations  may  be  combined 
with  the  traction,  but  they  should  never  be  made  so  powerful  or  free  as 
to  destroy  the  existing  adhesions.  We  ought  to  be  contented  with  a 
good  position  of  the  extremity,  and  not  to  risk  the  lives  of  our  patient 
for  the  sake  of  more  or  less  free  motion. 

In  adults  there  is  less  danger  of  recurring  disease,  and  their  limbs  bear 
a  freer  handling. 

The  fixing  of  the  pelvis  is  obviously  very  important  to  the  ulterior 
results,  and  the  hands  of  an  assistant  fail  particularly  then  to  fix  the 
pelvis  when  the  thigh  is  considerably  flexed  upon  the  former,  for  this  and 
the  purposes  of  after  treatment,  a  special  apparatus  is  needed. 

Buehring,  and  subsequently  B.  Langenbeck,  have  constructed  such 
apparatus,  but  they  are  costly,  complicated,  cumbersome  and  inefficient. 
After  various  changes  and  improvements  I  have  succeeded  in  construct- 
ing an  apparatus  which  meets  all  the  requirements,  besides  being  cheap 
and  simple,  and  may  be  attached  to  a  plain  camp  bedstead.     The  appara- 
tus which  I  submit  to  your  inspection  is  much  more  costly  than  is  neces- 
sary (Fig.  16).    The  essential  part  of 
the  contrivance  is  a  wooden  block  ac- 
curately adapted  to  the  posterior  half 
of  the  pelvis,  inclusive  of  the  tuber 
ischii.     Any  wood  carver  can  make 
it  if  you  furnish  him   a  plaster  of 
Paris  cast.      This  block  is   simply 
^pj     j(.  N  lined    with  chamois,    and,    if   well 

adapted,  the  patient  can  lie  in  the  same  for  months  with  the  same 
convenience  and  ease  with  which  a  gum  plate  with  artificial  teeth  may 
bo  worn.  When  the  patient  is  placed  in  this  block  he  is  fastened  down 
by  stout  leatherstraps  and  buckles,  in  front  and  across  the  pelvis.  This 
block  is  fixed  to  a  plate  of  sheet  iron  by  means  of  screws  from  below  ; 
and  the  iron  plate,  by  means  of  four  bolts,  to  the  frame  of  the  bedstead. 
Thus  you  have  a  simple  and  complete  fixture  of  the  pelvis  which  lies 
closely  upon  the  mattress.  (Fig.  17.)  All  that  remains  is  an  iron  frame 
at  the  foot  of  the  bedstead,  and  two  pulleys  to  shift  upon  the  frame. 

This  apparatus  should  be  in  readiness  when  proceeding  with  brisement 
forc4,  and  if  need  bo,  may  at  once  be  used  in  place  of  the  table  and 
in  preference  to  the  manual  fixing  of  the  pelvis. 

If  you  should  not  succeed  in  completely  extending  and  abducting  the 
extremity,  you  may  defer  the  completion  and  in  the  meantime  keep  the 
limb  in  the  same  position  in  whioh  your  first  attempt  left  it,  by  pulley 


85 


and  weight,  or  if  you  hav3  completely  succeeded,  the  after-treatment  may 
at  once  he  fairly  commenced.  In  these  cases  extension  comes  in  for  its 
profitahle  employment.  Without  myotomy  and  hrisement  forc6  it  is 
more  than  worthless  because  dangerous ;  in  combination  with  those  pre- 


(Fig.  17.) 
liminaries  it  is  a  most  useful  auxiliary.     Extension  with  the  aid  of  my 
apparatus  is  certainly  most  efficient   and  powerful,  since  the  pelvis  is 
completely  fixed,  and   the  patient  totally  prevented  from  assuming  an 
accomodating  position. 

I  have  used  it  with  great  benefit  in  a  large  number  of  cases,  and  know 
no  better  substitute. 
.  Two  or  three  months  will  suffice  to  render  the  newly  acquired  position 
stable ;  then  you  may  allow  locomotion  with  the  assistance  of  my  porta- 
tive hip  apparatus,  with  or  without  crutches  as  required. 

The  true  bony  anchylosis  of  the  hip  joint  finds  its  relief  in  Rhea  Bar- 
ton's opu'ation.  I  have  never  had  occasion  to  perform  it,  and  can  there- 
fore ofier  no  suggestions  drawn  from  personal  experience,  but  it  would 
seem  to  me  that  the  attempt  at  establishing  an  artificial  joint  at  the  line 
of  division  is  unwarrantable  for  two  reasons  :  1st.  An  artificial  joint  could 
never  give  a  sufficient  support  to  the  superstructure  of  the  body.  2nd.  It 
inevitably  protracts  the  suppuration  with  its  impending  ..anger  of  pyae- 
mia. 

Sayre,  a  few  years  ago,  performed  this  operation,  as  he  alleged  with 
success,  but  his  patient  nevertheless  died  a  few  months  after  from 
pyaemia. 


wsm 


86 

The  specimen  derived  from  the  case,  did  not  sustain  the  assertion  of 
that  gentleman,  no  cartilaginous  covering,  synovial  lining  or  a  new  cap- 
sular ligament  having  been  formed. 

Now,  gentlemen,  I  have  arrived  at  the  end  of  our  discourse  and  will 
finish  with  relating  a  few  interesting  cases.  Some  of  them  present  peculiar 
and  exceptional  clinical  features,  others  may  serve  as  types  of  their  class. 
Your  attention  has  been  most  gratifying  to  me  and  I  feel  sincerely  thank- 
ful for  your  magnanimous  indulgence. 


., 


Case  I.  '.-.', 

Hygroma  hursale  traumaticiiniy  of  eight  years  standing,  Jihrous  anchy- 
hsis  of  left  knee  joint  with  flexed  and  inverted  malposition.  (Vide  fig.  18 
and  fig.  12.) 

A  young  man  (Packner)  twenty  two 
years  old,  solitjited  my  professional  services 
in  the  following  case  :  When  at  the  age  of 
11  years  he  sustained  an  injury  to  the 
left  knee,  which  gave  him  trouble  for  three 
years,  not  materially  impeding,  however, 
his  locomotion.  His  general  health  hav- 
ing materially  suffered,  his  father,  a  sea- 
captain,  was  advised  to  take  the  patient  on 
a  voyage  and  give  him  the  benefit  of  sea- 
air.  On  ship  board  he  repeatedly  met  with 
falls  and  slight  accidents  without  being  ag- 
gravated. One  day  whilst  driving  a  naiJ 
into  a  plank,  the  hammer  struck  him 
heavily  just  above  the  left  knee-joint  and 
caused  a  painful  bruise,  soon  followed  by 
intense  agony  and  swelling. 

From  that  time  to  the  period  when  I 
took  charge   of  his  case,  the  patient  had 
.pj„  jg  X  never  been  free  from  pain  and  uneasiness, 

and  his  haggard,  anxious,  and  desponding  appearance  bore  the  unmis- 
takable evidence  of  severe  and  continuous  suffering.  The  affected  arti- 
culation was  so  tender  as  to  be  utterly  useless  for  locomotion;  in  fact  he 
would  not  even  stand  upon  the  extremity  with  a  mere  fraction  of  tho 
bodily  weight  put  upon  it.  Hence  crutches  were  requisite,  between 
which  the  extremity  was  suspended, 

The  wealthy  father  had  of  course  successively  consulted  the  best  sur- 


87 


geoDS  he  could  find,  both  in  Europe  and  on  this  continent.     They  had 
all  agreed  in  their  counsel  that  amputation  was  the  only  remedy. 

On  examining  the  affected  extremity  the  following  clinical  points  were 
elicited : 

1.  An  ovally  shaped,  smooth  and  throughout,  hard  tumor,  "  9  x  4," 
inches  located  immediately  above  the  knee-joint.  Its  base  was  broad, 
abrupt  and  immovable.  There  was  no  tenderness  or  discoloration  about 
the  tumor ; 

2.  The  joint  was  anchyiosed  but  allowed  a  trifle  of  motion,  which  was, 
however,  very  painful  at  its  inner  circumference  ; 

3.  The  quadriceps  muscle  of  the  thigh  was  displaced  to  the  outside  of 
the  tumor ;  the  patella  lodged  upon  and  adhered  to  the  external  condyle 
of  the  femur; 

4.  The  tibia  occupied  an  angle  of  150°  with  the  femur,  and  was  so 
turned  on  its  axis  as  to  evert  the  toes ; 

5.  Besides  there  was  a  slight  inflexion  at  the  knee  between  the  two 
bones  which  gave  it  a  knock-kneed  appearance  ; 

6.  The  biceps  muscle  was  considerably  shortened  and  therefore  very 
tense; 

7.  The  temperature  of  the  kaee-joint,  more  particularly  at  its  inner 
aspect,  was  not  much  raised  ; 

8.  In  fine  the  affected  extremity  was  moderately  attenuated. 

The  tumor  was  obviously  accountable  for  the  existing  articular  trouble 
and  malposition.  It  had  raised  up  and  gradually  displaced  the  extensor 
muscles  of  the  leg.  The  latter  derived  additional  physical  power  from 
acting,  as  it  were,  around  a  pulley,  being  converted  into  a  flexor,  rota- 
tor and  adductor  muscle  of  the  knee.  The  tibia  had  yielded  to  the  ab- 
normal traction.  The  torsion  of  the  joint  had  set  up  inflammation  of 
the  synovial  lining,  eventuating  in  fibrous  interarticular  adhesion  of  the 
articular  faces.  Reflex  contraction  of  the  biceps  muscie  had  ensued. 
Thus,  by  the  succession  of  mechanical  effects,  a  most  complicated  morbid 
condition  had  been  brought  about  in  course  of  time,  traceable  to  no  other 
cause  than  the  tumor.  The  still  existiug  inflammatory  action  at  the  in- 
ner circumference  of  the  knee-joint,  may  be  ascribed  to  the  abnormal  posi- 
tion of  the  extremity,  being  diagonal  through  the  femur  and  bearing  the 
weight  of  the  body  upon  the  internal  ligaments. 

But  the  all  important  diagnostic  question  centered  itself  upon  the 
nature  of  the  tumor !  The  apparently  very  hard  texture  suggested 
bony  structure.  For  ostoid,  the  tumor  was  too  hard  and  smooth, 
and  had  existed  far  too  long  a  time  to  sustain  the  suspicion  of  a  malig* 
nant  growth.    Periostitis  would  have  circumvented  the  femur,  and  not 


88 


■ 


exhibit  a  broad  and  flat  base.  Bone  abscess  vrould  have  distended  the 
femoral  tube  in  all  directions  and  at  that  size  would  have  become  softened. 
The  hardness  and  smoothness  of  its  surface  precluded  the  idea  of  an  osteo- 
sarcoma. 

The  evidently  traumatic  cause,  the  gradual  increase,  the  regular  form 
of  the  tumor,  and  the  anatomical  region,  pointed  directly  and  conjointly 
to  the  distension  of  the  subcrural  bursa.  Yet  there  was  no  fluctuation, 
and  that  ominous  hardness  was  left  unaccounted  for.  Nothwithstanding 
the  discrepancy,  I  commenced  most  carefully  to  explore  my  ground  with 
the  hope  of  detecting  fluctuation  ;  for  the  rather  indefinite  supposition 
suggested  itself,  that  the  resistance  of  the  vagina  femoris  might  ren- 
der the  tumor  both  hard  and  obscure  its  fluctuation. 

At  the  inner  and  lower  aspect  of  the  growth,  a  branch  of  the  saphena 
magna  perforated  the  aponeurosis  and  dipped  into  the  depth.  There  I 
felt  some  elasticity  and  very  indistinct  fluctuation,  sufficient  evidence  of 
fluid,  at  any  rate,  to  warrant  explorative  puncture.  The  patient,  a  very 
intelligent  young  man,  having  realized  the  probable  character  of  his  case, 
and  deriving  new  nope  from  the  proposed  proceeding,  readily  consented 
to  the  exploration. 

After  having  made  the  necessary  preparation,  I  proceeded  next  day, 
with  some  professional  friends,  to  the  patient's  dwelling.  I  met  with  but 
little  encouragement  for  the  operation,  either  on  the  part  of  colleagues  or 
the  relatives  of  the  patient.  The  former  dissented  ir,  toto  from  the  sug- 
gestive diagnosis,  and  the  latter  presented  the  authority  of  the  best  sur- 
geons of  the  country  as  objection  to  any  other  proceeding  short  of  amputa- 
tion of  the  thigh. 

The  trocar  bein^,  inserted,  about  §  xiv  of  a  straw-coloured  and  alkaline 
fluid  was  withdrawn,  whereupon  the  tumor  collapsed.  On  careful  exam- 
ination, the  empty  sac  and  its  contours  could  still  be  discerned ;  but,  of 
course,  the  previous  hardness  had  entirely  vanished. 

Having  thus  verified  the  diagnosis,  I  proceeded  with  the  second  part 
of  the  programme,  in  dividing  the  outer  hamstring,  breaking  up  all  ar- 
ticular adhesions,  and  in  fully  extending  the  extremity.  A  few  minutes 
served  to  change  the  condition  of  the  patient,  and  infuse  him  and  his 
friends  with  new  hopes  for  the  future.  It  could  hardly  be  anticipated 
that  pressure  alone  would  suffice  to  prevent  the  re-accumulation  of  the 
bursal  fluid.  In  order  to  close  up  the  old  depot,  I  was  induced  to  inject 
tincture  of  iodine. 

That  operation  was  followed  with  violent  inflamraatidn  and  suppuration 
of  the  bursa.  When,  at  last,  the  cavity  had  closed,  tho  quadriceps  mus- 
cle was  so  firmly  aglutinated  to  the  thigh-bone,  that  it  seemed  indifferent 


■■ 


vi> 


89 

whether  the  articulation  of  the  knee-joint  was  re-established  or  not.  The 
patient,  desirous  for  active  life,  declared  himself  quite  contented  with 
a  straight,  useful,  and  painless,  though  inflexible  extremity,  with  which 
he  is  now  able,  according  to  a  recent  letter  to  a  friend,  to  walk  his  fortv 
miles  a  day,  by  peddling  in  California. 

The  presented  photograph  fig.  12  is  the  appearance]of  the  patient  at  his 
discharge.  At  that  time  I  supported  his  extremity  with  a  straight  ap- 
paratus, with  which  the  patient  now  dispenses. 

That  the  hardness  of  the  tumor  was  simply  caused  by  the  constraint 
and  resistance  of  the  vagina  femoris,  will  be  admitted  without  further 
dispute.  And  we  noticed  the  same  symptom  in  the  case  of  Mr.  A.,  one 
of  the  great  hotel  proprietors  of  New  York.  We  need  h?rdly  say  that 
the  correct  treatment  of  Mr.  A.'s  case  depended  likewise  on  corr«^ct  dis- 
cernment of  the  tumor,  about  whose  character  and  structure  conflicting 
opinions  and  apprehensions  had  been  advanced. 

^  V^  ^^'^^  ^^'  '■--'■' 

Traumatic  diastasis  of  the  lower  epiphysis  of  left  femur.  Remarkable 
deformity  and  malposition  of  the  knee-joints.  Abnormal  lateral 
mobility.  Total  resection.  Recovery. 
Francis  Shaw,  a  lad  of  fourteen  years,  of  Irish  descent,  and  endowed 
with  robust  health,  presented  himself  in  October  1860,  at  the  clinic  of  the 
Brooklyn  Medical  and  Surgical  Institute.  He  came  at  the  instigation 
of  a  surgical  instrument  maker  to  get  my  advice  with  reference  to  the 
feasibility  of  a  mechanical  apparatus  to  steady  and  support  his  limb,  and 
to  render  it  useful  for  locomotion.  He  stated  that  he  had  acquired  the 
deformity  when  but  seven  years  old,  and  that  ever  since  the  trouble  had 
increased,  and  that  then  he  was  unable  to  use  his  extremity  to  any  pur- 
pose. To  the  best  of  his  memory  he  received  a  blow  at  the  knee-joint 
with  an  iron  rod,  which  gave  him  pain  and  disabled  him  for  a  short  time. 
A  physician  had  been  called  in  soon  after  the  injury,  but  finding  no 
undue  mobility  or  deformity  he  pronounced  it  a  simple  contusion,  and 
advised  rest  and  cold  fomentations.  These  directions  were  followed  for 
three  weeks,  when  the  patient  resumed  his  walk. 

Since  that  time  dates  the  impediment.  In  the  erect  posture,  the 
patient  throws  his  whole  weight  upon  the  sound  member,  when  balanced 
between  two  chairs  a  three  inch  block  is  required  to  equalise  the  length 
of  both  extremities,  as  may  be  seen  in  the  adjoining  diagram  (Fig.  19). 
The  left  limb  is  peculiarly  knock-kneed,  the  thigh  being  adducted,  the  leg 
abducted  and  everted,  and  laterally  both  forming  an  angle  of  120°.  This 
position  alone  would  have  been  quite  sufficient  to  render  locomotion  infirm 

G 


Hi 


90 

and  defective,  but  us  it  was,  the  limb  became  totally  useless  by  the  relax- 
ation of  the  knee  joint.  At  the  moment  the  patient  rested  upon  the 
affected  extremity,  the  leg  became  still  more  abducted  and  everted,  and 
the  angle  with  the  thigh  could  easily  be  reduced  to  80°  and  less.     Both 


(Fig.  19.     See  page  299.) 

articular  faces  moved  with  undue  freedom  over  each  other,  and  the  tibia 
could  be  freely  rotated  upon  the  femur,  the  scope  of  eversion  being, 
however,  greater.  This  abnormal  condition  was  due  to  some  re- 
markable anatomical  changes  in  the  configuration  of  the  joint. 
The  articular  surface  of  the  femur  had  an  oblique  direction,  from 
below  and  inward  to  up  and  outward,  the  two  condyles  were 
absent,  and  the  bone  terminated  below  us  a  segment  of  a  sphere, 
of  which  but  a  part  was  appropriated  for  articulating  purposes, 
the  patella  and  the  quadriceps  muscle  were  drawn  out  of  position  to- 
wards the  outer  aspect  of  the  extremity.  The  tendon  of  the  biceps  muscle 
occupied  the  popliteal  space.  In  every  other  respect  the  limb  presented 
the  ordinary  condition,  except  being  slightly  attenuated. 


91 


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c 

>- 
e 
d 


isefore  the  patient  had  applied  to  our  institution  he  had  presented 
himself  before  the  surgical  staflF  of  the  New- York  City  Hospital,  who  had 
come  to  the  conclusion  to  advise  mechanical  support,  which  was,  however, 
entirely  out  of  the  question.  On  the  other  hand  Francis  Shaw  had  ar- 
rived at  an  age  which  made  him  desirous  of  entering  upon  some  business, 
and  therefore  insisted  upon  some  means  to  render  his  limb  serviceable. 
There  was  nothing  left  but  the  exsection  of  the  knee  joint  or  amputation 
of  the  thigh ;  for  no  orthopaedic  ireatment  could  be  relied  upon  to  ma- 
terially alter  the  anatomical  status. 

I  could  not  hesitate  to  decide  in  favour  of  exsection,  since  both  the  con- 
stitution of  the  lad  as  well  as  the  bony  structure  concerned,  were  in  a 
most  auspicious  condition.  The  operation  was  performed  on  the  9th  of 
October.  I  had  to  remove  quite  a  large  piece  from  the  femur  so  as  to  obtain 
a  rectangular  surface  ;  but  a  very  thin  slice  was  taken  from  the  tibia, 
the  patella  was  likewise  removed.  The  bones  were  then  brought  in  close 
proximity  and    kept    in    position    by  softened   iron    wire,    and    the 

wound  united  by  silver  wire  in  fine,  the 
limb  was  secured  in  one  of  the  iron  splints 
(vide  fig.  10)  which  left  the  knee-joint  itself 
free  of  access.  Recovery  followed  rapidly, 
partly  by  first  intention.  The  bone  wire 
was  removed  on  the  twenty  sixth  day  after 
the  oijeration,  and  at  the  end  of  the 
second  month  the  patient  was  up  and  about, 
.and  accompanied  me  on  crutches  to  a 
[neighbouring  gallery  to  ha\o  his  photo- 
graph taken.     Represented  in  (Fig.  20.) 

On  the  28th  Feb.  1861,  -I  exhibited 
Francis  Shaw  at  the  New-HTork  Pathologi- 
cal society,  when  his  conditions  were  as 
follows :  integuments,  completely  cicatrized ; 
firm  union  of  the  bones  by  short  fibrous 
tissues  admitting  but  of  scanty  motion ; 
moderate  enlargement  of  the  circumfe- 
rence ;  circulation  and  temperature  normal ; 
deficiency  in  length  two  inches  ;  correct 
position  of  the  foot.  With  a  heel  of  two 
and  a  quarter  inches,  pelvis  and  shoulders 
stand  square.  His  locomotion  was,  aside 
from  the  stiffness  of  his  knee,  unimpeded. 
You  may  imagine  that  the  diagnosis  of  the  case  must  have  been   per- 


92 

plexing,  when  the  most  distinguished  surgeons  of  New- York  signally 
failed  to  realize  it,  nor  could  I  lay  any  claim  to  :i  clear  understanding 
of  the  proximate  cause  in  the  premises  before  the  operation,  yet  I  have 
the  gratification  to  say  that  the  views  I  V.id  first  formed  and  expressed 
to  my  class,  did  not  fall  short  of  the  ■  lality. 

That  the  injury  to  Francis  Shaw  nad  produced  no  fracture  was  self- 
evident  from  the  previous  history  so  clearly  related.  Nevertheless  the 
continuity  of  the  femur  must  have  suffered  in  such  a  manner  as  not  to 
disturb  the  form  of  the  limb,  nor  give  rise  to  any  undue  mobility. 
With  diastasis  of  the  lower  femoral  epiphysis  these  conditions  are  com- 
patible. Had  the  patient  quietly  remained  in  bed  for  six  or  eight  weeks, 
there  is  no  doubt  that  the  subsequent  trouble  would  have  been  averted. 
But  in  rising  prematurely,  the  soft  agglutination  of  the  epiphysis  with 
the  shaft  gave  way  and  allowed  the  former  to  turn  gradually  round,  and 
with  it  dislodge  the  entire  joint.  In  the  newly  acquired  position  the 
undue  pressure  upon  the  external  condyle  of  the  femur  had  gradually 
diminished  its  size  until  no  trace  was  left.  And  the  internal  condyle 
became  the  terminating  end  of  the  femur.  The  fragments  of  bone 
removed  by  the  operation  (fig.  21  and  22*),  render  this  reasoning  at  least 
plausible  if  not  conclusive. 


a 


(Fig.  22.) 


Case  III. 


Morbus  Coxarius  in  its  third  stage.  Consecutive  Abscess  connecting 
with  the  joint. — Complete  prevention  of  malposition. 

George  D.,  ten  years  old,  of  good  constitutior.  and  general  health,  de- 
scending from  healthy  parents,  and  one  of  nine  children  who  are  enjoying 
perfect  health,  came  twenty  months  ago  under  my    treatment.     His 

•  a.  Epiphyseal  line. 
0.  Internal  condyle  of  femur. 
e.  Slice  of  tibia. 
Fig.  22,  represents  the  posterior  view. 


93 


left  hip-joint  was  then  very  tender  and,  immovable,  the  extremity  was 
slightly  bent  upon  the  pelvis,  abducted  and  rotated  with  cvorsion  of  the 
toes.  The  pelvis  was  lowered  at  the  affected  side,  and  the  spine  conse- 
quently inclined  the  sunie  way.  On  examination  under  chloroform, 
it  was  found  that  the  hip-joint  was  almost  immovable,  allowing  but  slight 
flexion  and  extension,  but  no  adduction  and  rotation  whatsoever.  The 
tensor  vaginre  femoria  and  the  pectinaeus  muscle  contracted. 

There  was  but  a  moderate  fluctuation  at  the  joint.  In  addition  to 
this  I  was  informed  that  the  patient  complained  of  pain  at  the  knee  and 
violent  nocturnal  paroxysms.  The  limb  was  moderately  attenuated. 
Although  the  boy  had  manifested  the  symptoms  of  morbus  coxarius  but 
a  very  short  time,  he  gave  evidence  of  constitutional  sufifjring,  looked  pale 
and  thin.  A  full  diirectly  upon  the  left  hip,  was  assigned  as  the  osten- 
sible cause  of  this  disease. 

Those  symptoms  strictly  coincided  with  the  second  stage  of  morbus 
coxarius. 

The  treatment  was  initiated  with  leeches  to  the  affected  articulation. 
The  contracted  muscles  were  thereupon  divided  and  the  patient  was 
placed  in  the  wire  apparatus,  and  thus  rest  and  position  of  the  extre- 
mity insured. 

The  immediate  effect  of  this  treatment  manifested  itself  in  complete 
repose  and  immunity  from  pain,  both  structural  and  reflected.  This 
treatment  was  continued  for  six  months,  when  again  a  thorough  examina- 
tion was  instituted.  There  was  almost  complete  mobility,  without  cre- 
pitus ;  no  fluctuation  about  the  joint ;  the  limb  occupies  a  rectangular 
position  to  the  pelvis.  There  was  no  pain  on  pressure  or  motion.  The 
constitutional  appearance  of  the  patient  was  notably  improved,  appetite 
and  rest  were  perfect. 

Presuming  that  the  disease  had  been  effectually  arrested,  I  allowed  the 
patient  one  hour's  locomotion  per  day,  with  the  hip  splint  and  crutches, 
and  this  time  to  be  gradually  prolonged  provided  no  active  symptoms 
should  recur.  During  the  balance  of  the  day  and  the  night,  in  the  re- 
cumbent posture,  and  the  limb  again  secured  as  before.  There  was  no 
reason  to  alter  the  plan,  and  at  the  end  of  another  six  months  he  enjoyed  his 
full  freedom  and  went  regularly  to  school,  crutches  and  portative  appan?- 
tus,  as  well  as  the  wire  apparatus  during  the  night,  being  continued. 

About  four  months  ago,  an  abscess  formed  over  the  place  where  the 
tensor  vaginaD  femoris  had  been  divided,  and  was  attended  with  the  or- 
dinary signs.  It  was  punctured,  evacuated,  and  its  walls  kept  compressed 
by  flannel  bandage ;  since  then  it  has  three  times  refilled  and  again  been 
punctured.    Each  time  the  wound  closed.     The  matter  drawn  from  the 


mmmi 


94 

abscess  was  rather  thin  and  somewhat  soapy,  oontairiing,  however,  no 
structural  detritus  of  any  account,  and  particularly  no  elements  of  bone. 
I  am  rather  undecided  as  to  the  nature  and  meaning  of  the  abscess,  and 
have  no  means  of  ascertaining  whether  it  connects  with  the  joint  or  is 
the  consequence  of  suppurative  bursitis.  There  is  indeed  not  a  single 
symptom  indicative  of  the  joint  being  implicated,  although  the  possibility 
cannot  be  denied.  But  the  fact  that  the  punctures  close  and  form  no 
sinuses,  is  rather  against  articular  suppuration.  It  is  at  best  therefore 
an  open  question. 

On  the  other  hand  I  have  seen  these  abscesses  often  form  at  the  same 
location,  and  subsequent  to  the  division  of  the  tensor  vaginae  femoris. 
Not  unlikely  these  abscesses  grow  out  of  an  injury  to  the  bursa  of  that 
muscle,  and  would  have  no  great  pathological  import.  If  this  version 
should  prove  true,  the  diagnosis  of  this  case  should  be  modified  accord- 
ingly. From  the  general  aspect  of  the  case,  I  expect  perfect  recovery  at 
no  distant  time.     The  diagrams  (figs.  23 — 24)  represent  the  present 


(Fig.  23.)  (Pig.  24.) 

status  of  my  patient  in  as  far  as  the  position  of  the  afieoted  limb  is  con- 
cerned, and  it  will  be  observed  that  form,  position,  and  length  are  normal, 
not  even  the  circumference  of  the  limb  differs  materially  with  its  fellow. 


95 


Case  iv. 

Malposition  of  the  right  limb  with  more  than  four  inches  shortening, 
the  result  of  now  extinct  Hip  Disease. 

Harry  M.,  ele\  i  years  of  age,  came  under  my  charge  in  the  following 
condition.  The  right  extremity  considerably  attenuated ;  the  thigh  without 
its  proper  contours  \  extreme  adduction  and  inversion ;  pelvis  tilted  up 
and  rotated  backward ;  corresponding  deflection  of  the  spine ;  gait  very 
awkward  and  limping,  in  spite  of  a  four  inch  heeled  boot ;  trochanter  major 
protrudes  considerably,  and  exceeds  by  three  quarters  of  an  inch  a  line 
drawn  between  the  anterior  superior  spinous  process  of  the  ilium  and  the 
tuber  ischii ;  insignificant  mobility  of  the  articu'  '■  ,  without  a  trace 
of  abduction  and  rotation. 

These  impediments  were  the  consequences  of  morbus  coxarius,  since 
eighteen  months  entirely  extinct. 

/  Ithough  of  slender  build,  he  had  enjoyed  perfect  health,  and  been  a 
very  active  boy  up  to  the  very  time  when  he  was  suddenly  struck  down 
with  that  disease. 

There  is  no  morbid  diathesis  in  the  family  ;  the  father  of  the  patient 
is  even  a  very  robust,  muscular  and  astive  man,  the  very  picture  of  health 
and  manliness.  In  addition  to  this  the  patient  has  been,  and  is  still,  sur- 
rounded with  the  attributes  of  opulence  and  rational  hygiene.  The  pre- 
monitory symptoms  were  but  few,  insignificant  and  of  short  duration. 
When  at  a  boarding  school  in  the  country  the  patient  was  suddenly  at- 
tacked with  the  most  violent  symptoms  of  morbus  coxarius,  which  con- 
tinued with  unabated  intensity  for  five  months ;  then  they  almost  as 
abruptly  abated,  leaving  the  patient  in  that  deformed  state  which  I  have 
briefly  sketched.  But  the  shortening  had  steadily  increased  so  as  to  re- 
quire from  time  to  time  a  higher  heel  to  his  hoot.  Even  during  the  6 
months  preceding  the  operation,  the  increasing  shortening  of  the  limb 
had  been  observed.  He  had,  however,  completely  regained  his  standard 
of  excellent  constitutional  health,  and  was  as  active  as  before.  There 
were  no  local  symptoms  indicative  of  continued  joint  disease. 

I  have  not  been  able  to  ascertain  the  cause  of  the  original  attack. 
There  is  certainly  )  pretence  of  constitutional  causation,  although  the 
patient  does  not  remember  having  met  with  any  accident  worth  speaking 
of.  I,  nevertheless,  consider  myself  justified  in  assuming  the  same,  for  the 
very  activity  of  the  patient  seems  to  warrant  such  a  supposition,  still 
more  so  the  violent  character  of  the  disease  and  its  rapid  course  without 
suppuration. 

The  patient  came  under  my  treatment  in  the  spring  of  this  year,  and 
,jremained  four  months  with  me.     During  this  time  I  have  divided  sue- 


96 


cessively  most  of  the  abductor  muscles  ;  and  at  four  different  occasions, 
mth  the  assistance  of  chloroform,  broken  down  most  fibrous  adhesions, 
and  by  steady  extension  in  the  recumbent  posture  and  repeated  passive 
motions,  I  have  succeeded  in  placing  the  affected  extremity  in  a  rectaogu- 
lar  position  to  the  pelvis,  and  extended  and  loosened  the  still  existing 
fibrous  impediments  to  such  a  degree  as  to  allow  moderate  mobility  of  the 
articulation. 

From  the  high  position  and  pro^iinence  of  the  larger  trochanter,  it  is 
evident,  that  the  neck  of  the  femur  rides  upon  and  is  fastened  to  a  new 
articular  facet  at  the  superior  and  posterior  portion  of  the  acetabular  mar- 
gin, where  it  still  remains,  and  from  which  position  I  do  not  intend  to 
displace  it.  At  the  end  of  the  second  month  I  allowed  locomotion  to  the 
patient,  supported  by  crutches  and  my  first  hip  apparatus.  It  was  at  that 
time  that  the  photograph  (figs,  24  and  5)  were  taken.     You  may  judge  for 

yourselves  of  the  material  changes  to- 
wards  improvement  which  had  been 
effected  up  to  this  time.  Previous  to 
his  discharge,  another  photograph  with 
the  second  hip  instrument  applied,  was 
obtained,  (vide  fig.  7).  In  that  position 
the  pelvis  has  resumed  its  proper  level, 
the  extremity  stands  rect-angularly, 
within  five  eighths  of  an  inch  off  the  fioor. 
The  passive  motioDS  are  still  continued 
with  due  care,  and  daily  lubrications  are 
being  made  with  phosphorated  oil,  to 
promote  healthful  innervation  and  nutri- 
tion. 

The  patient  is   directed  to  wear  the 
hip  instrument  night  and  day  until  the 

changes  of  form  and  position  become  per- 
(Fig.  25.)  ° 

marent,  when  a  heel  ^  of  an  inch  higher  than  that  of  the  other  boot, 
will  sufiice  to  ensure  easy  gait  and  locomotion. 

These  changes  have  been  wrought  within  the  shorv  period  of  four 
months  in  a  deformity  and  malposition  which  in  former  times  were  con- 
sidered beyond  surgical  aid,  and  this  case  famishes,  therefore,  an  illustra- 
tion of  the  grand  progress  in  orthopaedic  surgery. 

Brooklyn,  N.Y.,  Clinton,  corner  of  Warren  steeet. 


staf 
oet 
noi 


rent  occasions, 
rous  adhesions, 
speated  passive 
•  in  a  rectanga. 
le  still  existing 
mobility  of  the 

rochanter,  it  is 
bened  to  a  new 
icetabular  mar- 
not  intend  to 
3omotion  to  the 
It  was  at  that 
I  may  judge  for 
al  changes  to. 
Ich  had  been 
,  Previous  to 
lotograph  with 
it  applied,  was 
n  that  position 
iS  proper  level, 
rect-angularly, 
ch  off  the  floor, 
still  continued 
iibrications  are 
lorated  oil,  to 
ion  and  uutri- 

i  to  wear  the 
.  day  until  the 
on  become  per- 
the  other  boot, 

period  of  four 
mes  were  con- 
are,  an  illustra- 


